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A study on causes of medication error
Medication error risks
A study on causes of medication error
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Regardless of efforts to decrease the occurrence of perioperative medication mistakes, however the errors remain an issue. There were examined done on 16 nurses who talked about medication errors in the perioperative environment and 11 other nurses who gave further information about perioperative mistakes, educating nursing staff, within that state. I have learned that the most frequently reported medication error was perioperative medication mistakes. There were other medication errors involved in intraoperative some examples are: medication administration, IV sedation, and "close call" events. Some of the reasons for medication errors are: making pressure, self-satisfaction, and failure to track established procedures. There was lack of
understanding between nursing units and specialty areas that can lead to medication errors. With the comparing of attitudes and opinions of nurses working in perioperative settings this can play a major role in medication errors as well as the non-perioperative areas. They both have similarities and differences in the perceptions of medication mistakes.
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.
Over the past several years extended work shifts and overtime has increased among nurses in the hospital setting due to the shortage of nurses. Errors significantly increase and patient safety can be compromised when nurses work past a twelve hour shift or more than 40 hours a week. Hazardous conditions are created when the patient acuity is high, combined with nurse shortages, and a rapid rate of admissions and discharges. Many nurses today are not able to take regularly scheduled breaks due to the patient work load. On units where nurses are allowed to self-schedule, sixteen and twenty-four hour shifts are becoming more common, which does not allow for time to recover between shifts. Currently there are no state or federal regulations that restrict nurses from working excessive hours or mandatory overtime to cover vacancies. This practice by nurses is controversial and potentially dangerous to patients (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). Burnout, job dissatisfaction, and stress could be alleviated if the proper staffing levels are in place with regards to patient care. Studies indicate that the higher the nurse-patient ratio, the worse the outcome will be. Nurse Manager’s need to be aware of the adverse reactions that can occur from nurses working overtime and limits should be established (Ford, 2013).
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
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 purpose of this paper is to show most of medication errors occur on the night shifts and the weekend shifts in pediatric care, Bar Code Medication Administration System’s success on extremely low medication errors in pediatric care, and tenfold medication errors in pediatric care.
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
Furthermore, short staffing affects the quality direct care each patient receives. The National Coordinating Council for Medication Error Reporting and Prevention (2012) states an estimated 98,000 individuals die every year from medical errors in the United States. One out of many significant tasks nurses do within their scope of practice is medication administration. Research shows a relationship between short staffing on medication errors: the longer the hours nurses work, the higher the chances of medication errors (Garnett, 2008). (include definition of medication error) Administering medications requires knowledge of patient rights, pharmacological information on the drug, adverse effects, proper dosage calculations, and hospital protocols. When nurses are assigned more patients, they are pressured to give due medications on time. Sometimes due to hunger or fatigue, nurses give the wrong medication to the wrong patient (Frith, Anderson, Tseng, & Fong, 2012).
Ethical dilemmas are the issues that nurses have to encounter everyday regardless of where their workplaces are. These problems significantly impact both health care providers and patients. Patient safety is the most priority in nursing and it can be jeopardized by a slight mistake. Medication errors and reporting medication errors have been major problems in health care. Errors with medications have been found to be the most common cause of adverse drug effects (Brady, Malone, Fleming, 2009). Northwestern Memorial Hospital in Chicago conducted a research in 2012 that approximately forty percent of the hospitalized clients have encountered a medication error (Lahue et al., 2012). A nurse’s role is to identify and report these medication errors immediately in order to stop or minimize any possible harm to the patients. Ethical moral dilemmas arise when reporting the mistakes that have been made by one’s own colleagues, acquaintances, peers, or physicians.
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.
Before starting this course and before reading the first section of Wall of silence: The untold story of the medical mistakes that kill and injure millions of Americans, I did not have much awareness of medical errors. My awareness extends to hearing stories about medical utensils and supplies being left in patients after surgery or hearing stories of patient receiving the wrong dose of medication, but hearing stories about the extent of deaths related to medical errors left me astonished. I was in awe reading the amount of deaths reported each year related to medical errors, not including the errors that are not reported. This book brings about the awareness and importance of implementing strategies to decrease medical errors.
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001; 29: 494-500.
Physicians ultimately decide what dose and drug will benefit the patient and restore them back to health. Held by the standards set by The College of Physicians and Surgeons, Physicians must abide by the Health Professions Act. Physicians are responsible to prescribe the right medication and right dosage. It is thought that physicians and other prescribers are ultimately to blame for medication errors. Although malpractices do occur among physicians, nurses are responsible to have a thorough understanding of the medications one administers to their patients. A nurse does not just simply do what they are told and administer drugs without having a thorough understanding and background knowledge. Nurses are to know the purpose of each drug they administer, the therapeutic effects, side effects which can be harmless or injurious, and adverse effects which is a severe negative response to the drug (2009). In reference to the previously mentioned scenario, the physician’s handwriting was careless and illegible. Although the Physician demonstrated lack of clarity, the nurse noticed the hastily written sentence signed by the physician and continued to administer the drug as she had routinely done the past couple days. Nurse’s should have a strong pharmaceutical knowledge background and be aware of the potential harm a medication could cause. In the process of medication administration, registered nurses are responsible to “determine that each medication order is clear, accurate, current and complete. Medications should be withheld when a medication order is incomplete, illegible, ambiguous or inappropriate; with concerns being clarified with the prescriber (CNO, 2015)”. The critical care nurse demonstrated ineffective communication, which was shown by failing to ask the physician for clarification. Another instance of miscommunication is during medication
Tzeng, H., Yin, C., & Schneider, T. E. (2013). Medication Error-Related Issues In Nursing Practice. MEDSURG Nursing, 22(1), 13-50.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).