...“One-third of all medication errors causing harm to hospitalized patients occur in the medication preparation and administration phase… (Smeulers, Verweij, Maaskant, Boer, Krediet, Nieveen van Dijkum & Vermeulen, 2015). Even though medication administration safety measures have been applied as healthcare continues to grow, there are still errors made. Safety measures have been implemented over the years in attempt to be thoroughly safe as one can be. However, administration of medications is still a target point for health care errors, as the nurse still must critically think before administering a medication to a patient. Using the Donabedian Model, structure is the first level to be examined to seek improvement in medication administration safety. Some examples of the structure level are facility, equipment, and staff and their qualifications (Shi & Singh, 2015). When discussing medication...
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...Reducing Medication Errors Medication errors are a major problem in the healthcare community, and especially in pediatrics. “Up to 27% of all pediatric medication orders result in a medication error.” Keiffer, Marcum, Harrison, Teske, and Simsic (2014). There is far less room for error with drug administration when working with pediatrics. It should be a primary goal to significantly reduce the cases of medication error in ever facility. I will discuss the importance of reducing medical errors relating to a Pediatric Cardiothoracic Intensive Care Unit. The article titled Reduction of Medication Errors in a Pediatric Cardiothoracic Intensive Care Unit discusses the rate of medication errors in their unit, and the steps that were taken to try to eliminate or reduce the number of medication errors. “A medication error is defined as an error that occurs with the prescribing, dispensing, administering, adherence, or monitoring of a drug regardless of whether it results in patient harm or has the potential to result in patient harm.” Keiffer et al. (2014). The authors note that medication errors occur more often with administration issues as opposed to prescribing, ordering dispensing, or monitoring. The article discusses the health care professionals’ courses of action taken to reduce medication errors for their patients. The medical team implemented interventions and methods including: a double check system, hands free communication, a safety systems checklist, a distraction-free...
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...Results The data collection procedures for this research is by observation of 118 health care professionals preparing medication preparation of intravenous narcotic preparation. Researchers were focusing on 2 potential approaches to reducing medication error, individual error focus and systematic error focus. Observing the health care professionals with different procedural changes, process design, to see if it reduces the possibility of error is the appropriate data collection. This research did not directly involve patient identifiable health information. This study was based off of the data from the original study that used some patient protected health information. This research studied the two possible approaches that would possibly effect the reduction in medication errors. The principles of validity and reliability are essential bases of the scientific method. Validity of research must have been randomization of the sample groups and appropriate care and diligence shown in the allocation of controls (Shuttle, 2008). The research is validated since the sample group is randomized with professionals within their field such as RN’s that are licensed to prepare IV mediations along with hospital pharmacists. Also controls were allocated with diligence. For example, the group in the research were randomly selected and the controls, such as the same medications and stations, were kept the same for each participation as much as possible. The reliability of the research is defined...
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...Medication Safety Medication plays a key role in healthcare but can also be an important key cause of medical error. Patients are entitled to receive safe care including receiving the correct medications. The administration of medication is a daily routine for nurses therefore, it is vital to remember the “Five Rights” of medication safety. The other issue that we are facing on the medical surgical floor is stress. The last issue is that staffs are being interrupted in medication room. Many different things can go wrong when it comes to the administering medication, for example communication between the patient and the nurse could go wrong, or the labeling of the medication, even the dosage can cause improper usage of the drug. The question is what role do nurses play when it comes to medication safety? Nurses play many different roles in the world of medicine; however the most important role is to assure that patients are receiving their medication safely. One of the recommendations to reduce medication errors and harm is to use the “Five rights: the right patient, the right drug, the right dose, the right route, and the right time” (Choo, Hutchinson & Bucknall, 2010). Verifying the patient’s identity ensures that the correct patient is receiving the medication, confirming that the medication written on the order is the same medication being prepared, ensures the right drug, dose and route is given. Some medications must be given at specific time, so it imperative to provide...
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...In the 1999 research studies began to review the problem of medical errors and how they occurred. Studies and reports, such as the Institute of Medicine IOM report in 1999, strongly suggest that most medical errors are related to systems and processes and not individual negligence or misconduct. The IOM report recommended that the key to addressing medical errors is to focus on improving the processes used to deliver healthcare and not placing blame on the individuals involved. Approximately 1.3 million people are injured annually in the United States following "medication errors". The FDA defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or harm to a patient”. The U.S. Food and Drug Administration (FDA) currently review medication error reports that come from drug manufacturers and through Med Watch, the agency's safety information and adverse event reporting program. The agency also receives reports about medication errors from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia. Some things the FDA has put into place to prevent medication errors: * Drug Name Review: To minimize drug name confusion, FDA reviews about 400 drug names a year that companies submit as proposed brand names. The agency rejects about one-third of the names that drug companies propose. * Drug Labels: FDA regulations require all over-the-counter (OTC) drug products (more than 100,000) to have a standardized...
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...Unfortunately this story does not resonate with some Americans who are far from happy about the level of care they received while sick. Quality problems are present in wide variation across board when talking delivery of health care services, in some instance, the issue could be with underutilization of a particular service, and other instances may include misuse of service which is generally preceded at onset by prior unacceptable level of errors. The purpose of this paper is to highlight medication errors as a health care safety issue. One solution involving automation would be explored since it has long been recognized as an important factor in reducing human errors in work processes. It is crucial to showcase this because numerous studies have substantiated the positive effects of health IT on quality and safety improvements, Slovenky & Menachemi (2011). A safety Initiative With new tools provided by the Affordable Care Act, hospitals can now aggressively implement programs with sole aim of assisting in the reduction of preventable errors. The act provides hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals, to support their efforts to reduce harm, McKinney & Zigmond (2011). The government predicted that this could save 60,000 lives over the next three years and potentially save up to $50 billion in Medicare bill. The federal government is encouraging providers to adopt and effectively use electronic health...
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...Safety and Quality Patient safety is a high-priority issue for all professionals including pharmacists. Patient safety is defined as ‘the prevention of harm to patients, including through errors of commission and omission’. The role of pharmacists has been clinically proven to improve many outcomes regarding patient health, including greater patient safety, improved disease and drug therapy management, effective healthcare spending, improved adherence and improved quality of life (Canadian Pharmacists Association, 2008). The focus on patient care stemmed from a 1999 US report by the institute of Medicine titled, ‘To Err is Human: Building a safer Health System’. This report detailed the costs of medical errors to the US economy and how medical errors numbered higher than deaths due to AIDS, motor vehicle accidents, and breast cancer, combined. The report went on to descried how errors can be reduced (Institute of Medicine,1999). For centuries, pharmacists have been the guardians/safeguards against "poisons" those substances which could cause harm to the public. Now more than ever pharmacists are charged with the responsibility to ensure that when a patient receives a medicine, it will not cause harm. As highlighted in a report produced in November 2009 "Pharmacy Intervention in the Medication-use Process - the role of pharmacists in improving patient safety", the involvement of pharmacists in patient safety can be as early at the prescribing phase and up to the administration...
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...Abstract Healthcare unlike many high-risk industries has made slow progress in improving patient’s safety. The role of nursing in improving medication safety has been largely underestimated. Much of the research undertaken to date in relation to adverse medication events has neglected the impact that nurses have or could have in improving patient safety. In examining literature regarding adverse medication events one can see the urgent need for significant improvement in medication practices and processes. In addition that this health care issue will only improve with the participation of all disciplines working towards a common goal of improving the safety of those in our care. Introduction Medications play a key role in healthcare but can also be a significant key cause of medical error and of adverse patient outcomes. Nurses by the nature of their roles in medication administration can be the last line of defense in eliminating or reducing adverse medication events. The administration of medication is a common and almost routine activity in a nurse’s daily work, yet it is fraught with complexity and risk for both the patient and nurse. As a student nurse working in partnership with a registered nurse I have observed a variety of practices in medication administration that have varied from what I have been taught in class. On reflecting on these practices and questioning nurses why such practice has been adopted has illustrated to me both the flawed processes and environment...
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...patient quality of care and physician’s efficiency. “CPOE is recommended by the Agency for Healthcare Research and Quality and the National Quality Forum as one of the 30 “Safe Practices for Better Healthcare.” The Leapfrog Group also recommends CPOE implementation as one of its first three recommended “leaps” for improving patient safety” (Computerized Provider Entry, p1p7). There are many benefits that CPOE’s provide such as eliminating problems with handwriting, reducing storage space, since they have taken the place of traditional paper-based charts, reducing medication errors, faster transmission of prescriptions to the pharmacy. The CPOE also offers alerts and decision making benefits to the physician. It can compare a prescribed medication to a patient’s allergy list and other medications that the patient is currently taking. If the CPOE system finds anything wrong, it will give an alert to the doctor to re-exam the orders the doctor has written. It can also provide the doctor with a list of alternative medications that might be better to...
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...Statistical Thinking in Health Care Case Study 1 Week 4 Mat 510- Business Statistics November 1, 2015 With information from the case we will attempt to address some explanations to the issue of medication errors being dispensed at HMO pharmacy. A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality shows the categories of dispensing errors. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the pharmacist, this list can be extended by the addition of three other categories: failure to detect and correct a prescribing error before dispensing; failure to detect a manufacturing error before dispensing; and failure to provide adequate patient counseling in order to prevent administration errors. These categories arise in other segments of the pharmaceutical patient care chain, but they are nevertheless important when one strives for a full assessment of the pharmacy's performance. (a-Chun Cheung, Marcel L Bouvy, and Peter A G M De Smet) I am going to attempt a process map to the best of my ability on filling process for HMO’s pharmacy, in which some key problems that the HMO’s pharmacy might be experiencing. A SIPOC diagram is a tool used by a team to identify...
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...Drug Errors Introduction Administration of medicines is a key element of nursing care. Every day some 7000 doses of medication are administered in a typical NHS hospital (Audit commission 2002). Drug administration forms a major part of the clinical nurses role. Medicines are prescribed by the doctor and dispensed by the pharmacist but responsibility for correct administration rests with the registered nurse (O'Shea 1999). Each registered nurse is accountable for his/her practice. This practice includes preparing, checking and administering medications, updating knowledge of medications, monitoring the effectiveness of treatment, reporting adverse drug reactions and teaching patients about the drugs that they receive (O'Shea 1999). The patient is expected to receive the correct medication at each drug round but several studies have shown that this is not always the case (Raju et al 1988, Ferner 1995). Medication errors do occur and are a persistent problem associated with nursing practice (O'Shea 1999). The aim of this paper is to answer the question: Why are nurses still continuing to make drug errors? In order to answer this question this paper shall examine the guidelines that nurses must adhere to when administering drugs, shall provide a definition of a drug errors, look at reasons why drug errors occur and approaches that are aimed at reducing drug errors on the ward. There are a number of pieces of legislation that relate to prescribing, supply, storage and administration...
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...which includes The Right Patient, The Right Medication, Right Dose, Right Route, Right time. Management Criteria: The criterion set by management is implementing the system which improves the problems existing in the current system and achieves its goals with the least possible cost due to the cut in funds by the Government. Analysis: There are many options that be considered to overcome the persisting issues. The first option is to introduce the Unit dose system. The unit dose system is a medication dispensing system which the doses are individually prepared and packaged for each individual patient in a bubble pack, which then labeled with the name of drug, patient, dose and the time the medication needs to be given, each bubble has the medication for five days. The main goal is to reduce the errors in medications and medication waste, nursing time involved in dispensing the medications to the patients and it will also reduce the inventory holding cost. The criteria would be to see if the system has reduced the errors and issues and how much cost does it saves and incur. Even though the option might help in reducing the errors and might save time that can be used somewhere else to treat more patients, but it isn’t cost effective and incur more cost than the bulk purchasing, and it requires more labor then in bulk purchasing which can be bought once and used for long period. Another option available is to apply the Bar-Code Medication and Administration system (BCMAS), this...
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... 1. INTRODUCTION..............................................................................................3 2. PROBLEMS IN PRESCRIBING MEDICATION...............................................3 3. FACTORS RESPONSIBLE FOR THESE PROBLEMS...................................5 4. CPOE AS AN APPROPRIATE SOLUITON.....................................................6 5. ISSUES RELATED TO USE OF THESE SYSTEMS.......................................8 6. OBSTACLES IN USING THESE SYSTEMS & WAYS TO REMOVE THEM.........................................................................................................................10 7. CONCLUSION................................................................................................11 8. REFERENCES...............................................................................................12 1. INTRODUCTION With the thought that the use of information systems like CPOE (computerised provider order entry) will enable better, safer and more efficient patient care, many hospitals have completed an aggressive implementation of these systems. In this case study, the author has shown both the positive and negative sides of these information systems. The author has emphasized on the benefits provided by CPOE systems to eliminate the errors and at the same time describes some serious issues and problems caused by the advanced technological systems. These systems are not very common in use...
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...Statistical Thinking in Health Care Case Study 1 Week 4 By Shirley Davis Dr. Sally Robison Mat 510- Business Statistics November 1, 2015 With information from the case we will attempt to address some explanations to the issue of medication errors being dispensed at HMO pharmacy. A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality shows the categories of dispensing errors. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the pharmacist, this list can be extended by the addition of three other categories: failure to detect and correct a prescribing error before dispensing; failure to detect a manufacturing error before dispensing; and failure to provide adequate patient counseling in order to prevent administration errors. These categories arise in other segments of the pharmaceutical patient care chain, but they are nevertheless important when one strives for a full assessment of the pharmacy's performance. (a-Chun Cheung, Marcel L Bouvy, and Peter A G M De Smet) I am going to attempt a process map to the best of my ability on filling process for HMO’s pharmacy, in which some key problems that the HMO’s pharmacy might be experiencing. A SIPOC diagram...
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...agree with you that all medication orders should be checked prior to administration to avoid any error from occurring. When I was a graduate nurse many, many years ago the first things that the nurses on my unit did after taking report from the previous shift was to check all physicians orders. We also would check that the ward clerk entered all the medication orders correctly in the medication book. After all the physician’s orders were checked, the nurse would then sign off on the orders. Back then everything was hand written. I held many medications while I spent several hours contacting physicians to clarify a medication order that was not legible. We did not have the availability of electronic medical records. Electronic medical records (EMR) are currently being utilized by many health care providers, hospitals and health care organizations. This is currently being utilized to reduce the repetitive paperwork, and lower organizational costs. By utilizing the EMR system, the data collected is now legible as compared to paper records and in doing so; medical errors...
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