...SCENARIO ANALYSIS According to the Medication Administration Process, there is a step missing from the scenario. The steps missing are Step 3, Step 4, Step 6, Step 7, Step 8, and Step 9. All these measures of accurate Medication Administration Process can be realized to be missing from the scenario due to what the nurse did or did not do, did right or wrong, at the right time or not. Some errors occurred during the Medication Administration Process in the scenario. The first error is that the unit clerk communicates the medication order to the nurse verbally while it should be written or typed. When a medication order is typed, it rarely leads to misunderstanding or errors. The second error is when the nurse takes medication from bin number...
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...Nurses are the fine line between medication administration errors and medication administration error prevention. Nurses should be required to go above and beyond to avoid medication errors for the safety of the patient. This paper includes studies on the nurses knowledge, adherence and opinions on two-nurse double-check method for medication administration. The research concludes the evidence proved to be insignificant. Keywords: time management, medication errors, patient safety, double-check medication administration THE LINK BETWEEN INDEPENDENT DOUBLE CHECK AND PATIENT SAFETY Introduction The risk of medication errors will always exist, despite the many methods of preventing medication administration errors. The steps of the medication administration process are vital for patient safety. Unfortunately due to the lack of nurses in hospitals, nurses tend to skip steps of safe medication administration because of patient load and the time required to perform the steps. Are double checks essential in preventing medication errors? A diabetic patient on the medical-surgical floor needs the...
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...Reducing Medication Errors In Hospitals Patient centered care and patient safety are the most important roles in nursing. “Serious medication errors are common in hospitals and often occur during order transcription or administration of medication” (Poon et al., 2010. p. 1). According to Seibert (2014), medication errors and related deaths cost the health care system billions of dollars yearly and that at least one error a day happens in all hospitals. “An estimated 450,000 adverse drug events medication errors that result in patient harm occur annually, approximately 25% of which are preventable” (Seibert, 2014. p. 1). One important aspect of nursing is drug administration. It is a multidisciplinary task including doctors, pharmacist...
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...Medication errors are flaws in the healthcare system that can result in injury, disease, and even death. There are ways to prevent these mistakes and to make a facility more safe by enforcing certain rules and regulations. In order for these rules to be effective, the entire healthcare team including doctors, nurses, pharmacy, etc., need to cooperate and work together. It's very common for someone to make a clumsy move which is why triple checking is becoming more and more effective today. First scenario: A patient was prescribed two completely different medications to her but with similar names. The first drug was hydroxyzine 100 mg PO QID as needed and the second was hydrochlorothiazide 25 mg PO daily. When the nurse was supposed to be giving the 100 mg dose of hydroxyzine they instead pulled four 25 mg hydrochlorothiazide pills from the automated dispensing cabinet. The nurse proceeded to administer the medication before using the barcode scanning system. Not using the barcode was her first mistake. The nurse scanned the barcode after the patient had already consumed the pills. A pop up error came up saying "medication not found" because the daily dose of hydrochlorothiazide had already been given that day. Thankfully, the patient survived this incorrect administration of medication with no side effects to report. The nurse in this scenario administered the wrong medication that ended up being four times the prescribed dose of something that had already been given...
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...Medication errors are a very serious patient safety problem. They can be described as any mistake or incorrect judgement of a prescription, in dispensing or administering medication. It can be the mistake of a doctor, nurse or pharmacist. In the USA the Institute of medicine reported that 44,000 to 98,000 deaths were caused by medical errors yearly. 7,000 of them due to medication errors. In addition, Johnson and Bootman calculated 116 million visits to doctors, 17 million visit to Emergency Department, 8 million hospital admissions and 3 million long-term care admissions per year due to medication errors (Kwabena 2004). There are three people involved in medicine. The doctor who orders the medicine, the pharmacist who supplies the medicine and the nurse who gives the medicine. Any mistakes in their roles will result in medication errors. Thus, there are...
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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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.... There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration. Adherence to established safety procedures by all healthcare professionals can help to reduce medication errors. Errors occurring during the administration process are likely due to one of the steps of the five rights of medication administration being omitted: the right patient, medication, dose, route, and time, with the most frequent errors resulting from omission, wrong dose, and wrong medication (Davidhizar & Lonzer, 2003). Factors that can exacerbate errors include problems with the drug distribution system, inadequate staffing levels, environmental factors (e.g., distraction), nurses working in unfamiliar units, and not following standard policy and procedure. According to Davidhizar and Lonzer (2003), the following strategies are useful in addressing...
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...html Errors that occur earlier in the medication process are more readily detected (~50% are prevented during the ordering stage) while very few (< 2%) are caught at the administration stage (bates et al., 1995). further, it has been noted that more than one third of medication errors occur at the latter stage (leape et al., 1995). because of the relatively high proportion of errors and the lack of success preventing them, error reduction strategies targeted at the administration stage High rates of preventable medication errors have been repeatedly reported in studies in the medical literature (Bates et al., 1995; Leape et al., 1995; Flynn et al., 2002; Kanjanarat et al., 2003). It is difficult, however, to cite a single number to define the extent of the medication error problem due to differences in institutions, study methodologies, error definitions, and other variables. On the high end of estimates, one study that compiled data from 36 institutions reported 19% (~1 in 5) of the medication doses studied over a 4-day period involved medication errors (Barker et al., 2002). These errors included wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). The number of these errors deemed potentially harmful adverse drug events (ADEs) was 7%. A comprehensive review of medication error studies cited in the Institute of Medicine (IOM) 2000 report on errors in the U.S. healthcare system suggests that preventable ADEs, i.e., harmful medication errors, occur...
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...the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario. Root Cause Analysis A root cause analysis, is a system that is used to develop a plan that will identifying the causative factors of an adverse event and formulate a plan to decrease the occurrence or chances of a sentinel event. A team consisting of , a member of the hospital administration, a pharmacist, a respiratory therapist, a charge nurse or nurse manager, a physician, and a member of the family board should be brought together to perform a root cause analysis in this case. These team members would have a meeting to discuss the factors that led to Mr. B’s sentinel event. The first step would be for the team to begin interviewing the staff involved with the case to gather as much data as possible. The data that would be needed include, Mr. B’s vital signs, laboratory results, pain scores, a history of medication that he was given during his time in the emergency room in addition to any home medications, and the monitoring that was performed by the nursing staff after he received the medication. Some causative factors that could have led to Mr. B’s sentinel event are, his tolerance to opiates, his clinical...
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...Medication Safety Patient safety is the first priority concern for leadership in all health care organizations. The medication delivery process is the most common intervention in health care system. For that reason medication safety is considered the most challenging and complex process in improving patient care and safety during hospitalization. Medication-related errors are serious and occur at a rate of about one per patient per day (Allan, 1990). It is a harmful practice affecting patient’s health and life. Some of these errors may result in death or inefficiency of organs functions. In addition, medication errors may financially affect the health care organization due to long patient stay in the hospital for advanced treatment (Presto, 2004). This research paper will provide highlights on medication errors definition, importance of safety during medication process, factors contributing to medication errors and effective factors in preventing medication errors. Medication errors were defined as a fault in medication that may occur at any stage of the process in ordering or delivering medications (Bates, Boyle, Vliet, Scheider & Leape, 1995), either an injury occurred or the potential for injury was present (Bates et al, 1999). These errors could occur in dosing error, which is common (Lesar, Briceland & Stein, 1997), or wrong route, or wrong time, or error in medicine rate and omission error (O’Shea, 1998). Also there are some situations such as missing a dose of...
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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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...given us additional options to combat human errors that we have merely had to cope with in less technologically advanced times. As little as an ounce of the wrong blood during a transfusion can be fatal. Barcoding technology and other similar systems that reduce reliance on human data entry and double-checking have potential to greatly increase productivity and accuracy (Porcella & Walker, 2005). In fact, “Use of bar code technology for patient and product identification is not only a future requirement of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), but is also a major tool for error reduction. Wireless technology enables use of bar code equipment at the patient bedside, maximizing process efficiencies.” (Porcella & Walker, 2005) This paper reviews and analyzes the effects barcoding technology has had on the field of blood transfusions and patient safety as well as the resistance observed in clinical practices and the limitations on the technology due to cost of deployment. Barcoding to Prevent Incorrect Blood Transfusions An Analysis of Evidence Based Practice On July 22, 2003 a technician at Inova Fairfax hospital went into a patients room to draw blood for a type and cross because the patient was scheduled for surgery the next day. Apparently checks weren’t completed correctly and the technician drew blood from the wrong patient. The next day the patient received two pints of the wrong blood during a bowel resection and the patient...
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...Why Are There So Many Deaths Caused By Medical Errors and What Solutions Can Decrease Them? Health Service Systems – HSM541 June 20 2015 Background Medical errors kill at least 44,000 people and perhaps as many as 98,000 people per year. Or do they kill over 180,000 per year? Maybe even 440,000 people killed by medical errors? Allen (2013) In 1999 the Institute of Medicine (IOM) published a report titled “To Err Is Human: Building A Safer Health System” that leveled the healthcare community. They reported that according to two studies “perhaps as many as 98,000 people die in hospitals each year as a result of medical errors that could have been prevented”. IOM (1999) Then the Office of Inspector General for Health and Human Services followed up with a report in 2010 that stated “bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year”. Allen (2013) And finally in 2013, the numbers were once again raised. Per a report from the Journal of Patient Safety that approximately “440,000 PAEs (preventable/potential adverse events) that contribute to the death of patients each year from care in hospitals. This is roughly one-sixth of all deaths that occur in the United States each year”. They are now the U.S.’s third leading cause of death, behind only heart disease and cancer. All of the numbers mentioned in the first paragraph are medical errors that were “preventable”. Mistakes by the people you put your trust in killed you...
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...Medication Dispensing Errors and Potential Adverse Drug Events before and after Implementing Bar Code Technology in the Pharmacy Eric G. Poon, MD, MPH; Jennifer L. Cina, PharmD; William Churchill, MS; Nirali Patel, PharmD; Erica Featherstone, BS; Jeffrey M. Rothschild, MD, MPH; Carol A. Keohane, BSN, RN; Anthony D. Whittemore, MD; David W. Bates, MD, MSc; and Tejal K. Gandhi, MD, MPH Background: Many dispensing errors made in hospital pharmacies can harm patients. Some hospitals are investing in bar code technology to reduce these errors, but data about its efficacy are limited. Objective: To evaluate whether implementation of bar code technology reduced dispensing errors and potential adverse drug events (ADEs). Design: Before-and-after study using direct observations. Setting: Hospital pharmacy at a 735-bed tertiary care academic medical center. Intervention: A bar code–assisted dispensing system was implemented in 3 configurations. In 2 configurations, all doses were scanned once during the dispensing process. In the third configuration, only 1 dose was scanned if several doses of the same medication were being dispensed. Measurements: Target dispensing errors, defined as dispensing errors that bar code technology was designed to address, and target potential ADEs, defined as target dispensing errors that can harm patients. Results: In the pre– and post–bar code implementation periods, the authors observed 115 164 and 253 984 dispensed medication doses, respectively...
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...Final Project N311 Dr.Peggy Shipley Shannon McKnight 6/14/2014 2. Introduction According to the Institute of Medicine there are more than a million injuries and almost 100,000 deaths associated with medication administration errors every year in the healthcare profession. Administration of medication is a large part of every day nursing care. As the patient’s primary advocates, it is the nurse’s responsibility to make certain these medication errors do not occur and to uphold the patient’s safety. Hebda & Czar (2013) state, “The desire to reduce or eliminate medication errors focuses attention on computerized physician order entry (CPOE), Bar Code Medication Administration (BCMA), and e-prescribing”. With the growing amount of medication errors, many institutions are introducing the Bar Code Medication Administration System. This is a system that will aid in assuring the right patient is getting the right medication and reduce the risk for medication errors. Although BCMA will not be a remedy for medication errors, it can provide a safeguard that is not possible with manual method. The implementation of the Bar Code Medication Administration system has been highly proven reduce the number of medication errors, improve patient safety, and increase the nurse’s job satisfaction. 3. Barrier to the Implementation Understanding the barriers to change is one of the first...
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