Medication Errors

The American Society of Hospital Pharmacists define a medication error as “episodes of drug misadventure that should be preventable through effective systems controls involving pharmacists, physicians and other prescribers, nurses, risk management personnel, legal counsel, administrators, patients and others in the organizational setting, as well as regulatory agencies and the pharmaceutical industry” (Armitage, G. , & Knapman, H. 2003 ). This paper shall discuss the various causes of, and methods for the prevention of medical errors.

In looking at this important and complex topic it is hoped that healthcare providers will be made aware of situations and conditions that have the potential to lead to medication errors. With an expanded knowledge of this the healthcare provider will be better equipped to prevent a medication error from occurring. A reduction of medication errors is highly desirable so that the patient’s quality of care is at the highest level, and any adverse effects due to medication are minimized to the fullest extent. In the first article reviewed, Adverse events in drug administration, the topic discussed is the causes of medication errors.

The article first defines a medication error and then discusses problems with establishing an accurate count of medication errors “the issue of under reporting … is due to either a lack of appreciation that an error has occurred; the error is not considered serious enough to report; or … there is a reluctance to report” (Armitage, G. , & Knapman, H. 2003). Many of the situations environments, and conditions that facilitate the occurrence of medication errors are discussed in the remainder of the paper.

The second paper reviewed, Nature of preventable adverse drug events in hospitals, firstly deals with the frequency of medication errors “The reported median frequency of preventable adverse drug effects was 1. 8%” ( Kanjanarat, P. , Winterstein, A. G. , Johns, T. E. , Hatton, R. C. , Gonzalez-Rothi, R. , & Segal, R. 2003). It then discusses the drugs most commonly associated with medication errors. Types of errors, that is which of the five rights was violated, is then examined. Finally the type of adverse outcome, and major body system affected by the error is discussed..

The third paper reviewed, To Err is Human, To Share is Devine, mainly deals with the importance of the reporting of both medication errors and near misses. “Practitioner reporting and sharing of incident information internally and externally can enhance patient safety by helping to prevent recurrence of similar events”. (Koczmara, C. , Dueck, C. , & Jelincic, V. , 2006). Several specific examples of medication errors and near misses are given along with the resulting changes made to the aspect of the system that was the main contributing factor in the incident.

In the fourth paper reviewed, Heparin Error Highlights Risk and Need for Health Care Risk Managers to Take Action, a single medication error is looked at in detail. This incident involved a dosage mistake with heparin. “… containing 10,000 units per milliliter of heparin instead of the common dosage of 10 units per milliliter. The report found that the children actually received two of the vials. ” (Heparin Error Highlights Risk and Need for Health Care Risk Managers to Take Action, 2008 ). The root cause of this medication error was found to be product labeling as both the lower and higher dose drugs had very similar labeling.

Media attention resulting from this medication error led to the drug manufacturer to change product labels. Several suggestions are then presented on ways for hospitals to change systems and procedures in order to prevent a recurrence of such an error. Overall any medication error has a negative impact on client care. While a medication administered at the wrong time has little potential for an adverse effect if the wrong drug or wrong dose is given the potential for harm is much greater. In either case patient care has been compromised and is not up to the highest standards which is the main objective of the nursing profession.

The most common medication errors result in only minor adverse affects “ In appropriate drug therapy most often results in an allergic reaction or affected the skin (34. 4%)” (Kanjanart P. , et al). However the second most common medication error can be much more serious “The next most frequent adverse outcomes were hepatoxicity or nephrotoxicity (14. 3%)” (Kanjanart P. , et al). This highlights the need for the health care provider to be vigilant in ensuring medication errors do not occur. The impacts of medication errors on nursing can be emotional.

These can range from mild annoyance due to an increased paperwork load from filling out near miss reports etc. to feeling of being a failure for allowing a medication error to happen. “Error reports received reflect how practitioners… can suffer feeling of great responsibility and failure. ” (Koczmara, C. , Dueck, C. , & Jelincic, V. , 2006). On a system wide scale the effects may also be negative such as increased risk of liability. However there may also be some positive benefit form medication errors.

If the root cause(s) of the medication error are identified systems and procedure may be modified to address short comings and thereby improve the effectiveness and efficiency of the system. A specific example that shows both an impact on patient care and nursing is as follows. “Two error reports were received involving the mix-up of morphine 2 mg/ml and 10 mg/ml ampules resulting from substitution errors with look-alike packaging. One patient required treatment with naloxone and the other required additional monitoring, ISMP Canada alerted the manufacturer who subsequently made changes in their packaging.

” (Koczmara, C. , Dueck, C. , & Jelincic, V. , 2006). Additionally from the preceding example we can see the positive effect of reporting medication errors. In that case it took only two reports to affect a change in the system towards preventing further errors from happening. Also from a liability standpoint up front reporting of medication errors is a good thing. “ … the likelihood of being sued after such an error often depends on how the hospital responds when the error is discovered. If they revealed the error, and then made attempts to change the process that results in this error, that is always a good start.

” (Kanjanarat, P. , et al). These two examples highlight the importance of reporting medication errors and near misses. Nurses as the front-line healthcare providers shoulder a great burden of responsibility in the prevention of medication errors. “ Front-line health care practitioners are often safety nets preventing errors from reaching patients. ” (Koczmara, C. , Dueck, C. , & Jelincic, V. , 2006). It is because of this that every effort should be made with regard to implementing effective strategies to reduce the risk of medication errors.

The five rights, right route, right drug, right dose, right patient, right time are critically important. If these are combined with the three checks, before the drawer, before you pour, and before the drawer, the chances of a medication error occurring can be reduced. In ensuring that none of the five right are violated there are many useful strategies that may be employed. Critical thinking is the most important aspect of a medication error reduction strategy “It is not solely a mechanical task to be preformed in strict compliance with the written prescription of a medical practitioner.

It requires thought, and the exercise of professional judgement. ” (Armitage, G. , & Knapman, H. 2003). No system or procedure works in 100% of situations, the only counter effect that can deal with this is critical thinking. Taking adequate time to prepare properly is also an effective way to help prevent medication errors. “.. the increasing pace of work in hospitals may increase error rate… ” (Armitage, G. , & Knapman, H. 2003). With enough time to prepare it is possible to employ additional strategies to help reduce the chance of medication errors occurring. A main component of this is to check drug labels very carefully.

As was noted earlier in the example of the drug error with heparin, many drugs may have very similar labeling and careful examination of the labels is required to prevent mix-ups. Another important aspect is to double check dosage calculations. This counter intuitively may apply even more to experienced nurses than newer nurses. “… years of nursing experience have no bearing on nurse’s mathematical ability in calculating dosages. Interestingly, experienced nurses tended to have greater confidence in their ability but did not demonstrate a greater ability. ” (Armitage, G. , & Knapman, H. 2003).

An important requirement for all these strategies to be effective is a quiet environment free from distractions and interruption. One study found in a large portion of medication errors lack of a quiet environment was a factor in the error. “… found that 32% of the sample believed that distractions and interruptions were a key factor. ” (Armitage, G. , & Knapman, H. 2003). As we have seen, although the rate of medication errors is relatively low they have a negative impact on patient care. This is undesirable because as front-line health care providers patient care is our most important priority.

As such it is of the utmost importance to employ every strategy available to work towards preventing medication errors. Often this may start with just being aware of the most common errors and the situations and environments that lead to them. Armed with this knowledge health care providers can employ effective strategies to combat these causes. Ensuring that the five rights are not violated with critical thinking and good work practices goes a long ways to ensuring medication errors do not occur and should be strived for at every opportunity. In doing this as nurses we will be able to provide the very best level of care to our patients.

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