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Patient safety and risk management
The importance of good communication skills in healthcare
The importance of good communication skills in healthcare
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Patient Safety Assignment: Medication errors
Patient safety is described as “"freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and process that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur"(Kohn et al., 2000, p. 211). Throughout this essay I will discuss the patient safety problem of medication errors and the policies that have been put in place to ensure patient safety. The problems linked with medication errors vary from communication errors to insufficient staffing number. While it’s impossible to completely ensure that no errors will occur, it’s the job of healthcare professionals to lower risks and provide safer patient care.
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Almost all patients take multiple types of medications during each drug round and it’s vital that the nurse understands what each drug is responsible for. In order to prevent any administration issues nurses should follow the “5 rights” which outline the checklist of the right drug, right dose, right route, right patient and right time to ensure patient safety. Often mistakes are made as nurses give medications at the wrong time. Nurses should also be aware on the needs of the patient taking the medication. Nurses have the closest contact with the patient and are likely educated about any difficulties they have with their medication before any other healthcare professional. For example, some patients may have difficulty swallowing large tablets therefore it’s the responsibility of the nurse to inform the doctor and inquire about an alternative form of the drug. Nowadays most drugs are available in soluble forms and the nurse should be educated on all forms …show more content…
Within a hospital the "pen to patient” (Benjamin DM., 2003) steps are often complex which led to miscommunication and can have life threatening affects to the patient. Often it can be extremely difficult to understand the doctor’s handwriting on a patient’s drug kardex which can lead to medication errors. Healthcare providers also use many abbreviations when writing notes and prescriptions which may be misinterpreted. Therefore, healthcare providers should avoid using complicated abbreviations and ensure that their writing is legible for others. Also if the drug dose isn’t written clearly the wrong amount could be given and have disastrous consequences. Calculation errors are another major factor in medication errors. It’s vital that healthcare providers calculate the correct dose as even the smallest margin in difference can have a huge impact on the patient’s safety. The nurse should be 100% certain that they are giving the correct dose and if there is any doubt, they should double check their calculations with someone
...estions if not 100% sure of something or use a double checking system. When a nurse is administrating medication, they should use the ten rights of medication administration (right patient, right drug, right route, right time, right dose, right documentation, right action, right form, right response, and right to refuse). Nurses should always keep good hand hygiene and always wear appropriate clothing to prevent from the spread of disease. Good communication with patients and healthcare team members is also key to success. Keeping on the eye on the patient within an appropriate time is important. If the patient ever seems to be looking different than their usual self vitals should be taken immediately. Encouraging patients to ask questions if they are unaware of something can prevent errors as well. Nurses should make sure the patient is on the same page as they are.
Medication errors in children alone are alarming, but throw an ambulatory care setting into the mix and it spells disaster. When it comes to children and medication in the ambulatory care setting, the dosage range is drastically out of range compared to those that are treated in the hospital setting (Hoyle, J., Davis, A., Putman, K., Trytko, J., Fales, W. , 2011). Children are at a greater risk for dosage errors because each medication has to be calculated individually, and this can lead to more human error. The errors that are occurring are due to lack of training, dosage calculation errors, and lack of safety systems. Medication errors in children who are receiving ambulatory care can avoided by ensuring correct dosage calculation, more in-depth training of personal and safety systems in place.
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly graduated and experienced nurses. International Journal Of Nursing Practice, 18(4), 317-324. doi:10.1111/j.1440-172X.2012.02052.x
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
The Medication Administration Accuracy Project is a quality improvement project, whose purpose is to improve the accuracy of nursing medication administration. The study used for this project was to find where the most common “wrong doings” happened in the medication process and how to get rid of it. After a year of this project the medication error percent went from 4.3% in 2010 to 1.2% in 2011. The Bar Code Administration System implementation had been very successful with a 95% success rate every year that it is done. The study provided important insight on reducing the medication errors in children. Some were: making sure there are no distractions as possible, double checking medications and making sure the dose in adequate range for the child, and making sure you have two ways of identification with the bar code scanning (Hardmeier, A., Tsourounis, C., Moore, M., Abbott, W., Guglielmo, J.
Every day there is a constant trust adhered to many different people in the profession of Nursing—the decision of what will help patients in terms of medicine, and the confidence to make these decisions. One false act or one slight misdiagnoses of medication to a patient could be the prime factor in whether the patient lives or dies. Nurses in hospitals across the country are spread thin, and thus makes the probability of mistakes higher. If a medicinal dose is off by even one decimal a patient could die, so the only real answer is for nurses to not be afraid to ask for assistance, always follow procedure and voice opinion is they feel something is wrong.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
The topic of this article is medication error related to chemotherapy drugs. Forty percent of medication errors have been related to chemotherapy drugs. It is imperative that the nurses are properly trained on these medications and fully understand what is being administered before giving it to the patient as well as know what the proper dose is before administering anything to the patient. More importantly the nurse must pay close attention to their patient’s response to the chemotherapy given to the patient or it could lead to a serious injury or death.
Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of the nursing profession, taking up to forty percent of a nurse’s time in providing nursing care (Fowler). Consequently, nurses are commonly held accountable for medication errors. To improve the safety of a vital aspect of nursing care, bar code scanning was introduced to reduce errors in medication administration. Although bar code scanning has its advantageous aspects, there are also disadvantageous qualities.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
Firstly, nurses are expected to practice evidence-based health care hence a mastery of information about the essential and safe dose of drugs for a patient is very important for a nurse. Consequently, it could be the determinant between the life and the death of the patient. Pharmacology is a discipline which is mandatory for the nurse to excel in to be efficient in discharging his/her duties. Understanding which drug to use, the right dosage, the expected side effects which may occur and the contra-indications of the various drugs are key in the preservation of
Trounce, J. (2000) Clinical pharmacology for nurses: the role of the nurse in drug administration. 16th Ed. London: Churchill Livingstone.
Care planning is one of these tasks, as expressed by, RNCentral (2017) in “What Is a Nursing Care Plan and Why is it Needed?” it says, “Care plans provide direction for individualized care of the client.” A care plan is for an individual patient and unique for the patient’s diagnosis. It is a nurse’s responsibility to safely administer a patient’s medication prescribed by the doctor. Colleran Michelle Cook (2017) in “Nurses’ Six Rights for Safe Medication Administration,” she says, “The right patient, the right drug, the right dose, the right route and the right time form the foundation from which nurses practice safely when administrating medications to our patients in all health care settings.” Nurses must be safe when dealing with medications, and making sure they have the right patient. Nurses document the care that is given to their patient, as said by, Medcom Trainex (2017) in “Medical Errors in Nursing: Preventing Documentation Errors,” it states, “Nurses are on the front lines of patient care. Their written accounts are critical for planning and evaluation of medical interventions and ongoing patient care.” Nurses must provide an exact, complete, and honest accounts of everything that happens with a patient. Doing this allows for the proper evaluation, and medical interventions for the patient. The typical tasks a nurse involves care planning, administration of treatments and medication, and documenting the care given to a
I was also responsible for monitoring medication orders and reviewing patient profiles to ensure that the proper drugs and dosages were prescribed and that the pharmacy technician had prepared them properly. In many instances there were mistakes made in the preparation phase and sometimes even before, with incorrect dosages or drugs being prescribed and prepared, which could result in serious adverse effects for the patient. A clinical pharmacist’s role, however, is to make sure that these mistakes never reach the