Roughly over 1.5 million people are injured annually in the United States from medication errors. It is the fourth leading cause of death in the United States. According to the National Counsel for medication error Reporting and prevention defines medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medications in the control of the health professional, patient or consumers. Medication errors are surprising common and costly in all nation. Medications administration is a complex multistep process that encompasses prescribing, transcribing, dispensing, administering and monitoring patient’s response. An error can occur at any step in this process however many errors arise at the prescribing and administering stage which is sometimes intercepted by nurses, unit’s clerks, pharmacist and other staffs. Statistic on Medication errors
In a study by the Food and drug Administration (FDA) that evaluated reports of fatal medication error from 2002 to 2006, the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Giving the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. The study also reported older people maybe at greatest risk for medication errors because they often take multiple prescription medications (Stoppler 2013).
According to the institute of medicine one study estimated 380,000 preventable errors in hospital each year and another estimated 450,000 and the committee believes that both are likely to be underestimates. Another study reported 800,000 preventable errors in long term care facilities. These errors are very costly to patients, hospital, families, insurance companies and health care providers. Each preventable error in hospital can cost about $8.750 to the hospital stay. Assuming 400,000 errors the total annual cost would be $3.5 billion. (Brenan 2006) Key elements of Medication Use
The institute for safe Medication Practice has identified key elements with
the greatest influence on medication use, noting the weakness in these can lead to medication errors through Patient information, drug information, inadequate communication, drug package, environmental factors, patient education, staff education, competency and quality process (Anderson & Townsend 2010). Many medication errors stem from miscommunication amount pharmacist, nurses and physician. Poor communication among team’s accounts for more than 60% of the root causes of sentinel events reported to joint commission (Anderson & Townsend 2013).
One way to promote effective communication among team members is to use SBAR methods (situation, background, assessment and recommendation) when in doubt or when documentation is not clear. Health care organization should ensure that all medications are provided in clear labeled unit dose package institutional use because packaging for many drugs looks alike. Look-alike or sound alike medications product can be confused because their names look alike or sound alike. From 2003 to 2006 25,530 such errors were reported to the Medication Error Reporting Program. The Joint Commission require healthcare institution to identify look alike and sound alike drugs each year and have a process in place to help ensure related errors don’t occur (Anderson & Townsend 2013).
Environmental factors play a major step in medication errors, such as inadequate lighting, clustered work environments, increased patient acuity, distraction during medication preparation and administration and caregiver fatigues. To reduced interruptions, Sentra Leigh Hospital in Virginia institute a no interruption zone around the automated medication dispensing machines to prevent interruption during medication process. At my facility there is a sign at each medication cart that says no interruption during medication process. The staffs know not to interrupts the nurses during this process. Medical Errors
Josie Kings was 18 months old when she died at Johns Hopkins Hospital, one of the best Hospitals in the world. She had suffered first and second degree burns from climbing into a hot bath. She healed well and within weeks was scheduled for release. Two days before she was to return home she died
of severe dehydration and misused narcotics (www.josie.org). This Story is used to inspire caregivers and hospital administrators to take up the cause of patient safety in their daily work. The human cost of medical errors can easily be overlooked within training on patient safety. The Josie King Story showcases a mother who asks medical professionals to look, listen, and communicate to create a culture of patient safety. Over 1,200 healthcare institutions around the world use t he Josie King Story as training tool to emphasize the importance of communication and teamwork in patient safety (www.josie.org). At a Florida hospital nurses mistakenly gave two pregnant women a drug commonly used to force dead fetuses out of the womb. One woman lost two unborn twins and the second gave premature birth to a daughter who suffered severe brain damage. Ms. Sampson was five-and-a-half months pregnant when her doctor ordered her to strict bed rest.
Instead of giving her the progesterone suppositories to prevent premature labor, the hospital staff mistakenly gave her a dosage of Prostin. This is a powerful drug used to induce labor and expel fetuses out of the womb after miscarriages. The hospital described the incidents as an unfortunate error that occurred despite the safeguards they had in place Patel (2009). After working a 16-hour shift, a labor/delivery nurse gives the wrong medication. The physician had ordered an antibiotic to be given right away. The nurse picked up what she thought was the antibiotic and hung it without scanning the patient or them medication. Tragically, the drug she actually gave wasn’t the antibiotic but bupivacaine-fentanyl, an epidural anesthetic. The patient died within an hour. The nurse was charged with felony neglect of a patient causing great bodily harm, but pled guilty to the misdemeanor of dispensing and illegally obtaining a prescription. Her nursing license was suspended for 9months and she was barred from working in labor / delivery or critical care or any shift over 12hrs. (Anderson & Townsend 2013). Consequences for the Nurses
For a nurse who makes medication error, consequences may include disciplinary action by the state board of nursing, job dismissal, mental anguish and possible civil or criminal charges. Many employees felt immobilized, nervous, fearful, guilty and anxious. Many experience insomnia
and loss of self-confidence (Anderson & Townsend 2013). Avoiding Medication Errors
One should always be conscientious when giving medications and also meticulous about performing the five rights: the right person, right dose, right route, right time and right drug. One should always use the safety resources available at their facility and should not work around to bypass safety system because they are put in place for specific reasons. When nurses routinely bypass safety system and create workaround, the employer should conduct a root-cause analysis to identify the reason for the work-around and take action to correct the situation and prevent recurrences. Avoiding medication errors required vigilance and the use of appropriate technology to help ensure proper procedures are followed. Computerized physician order entry reduces errors by identifying and alerting physician to patient allergies or drug interaction, eliminating poorly handwritten prescription and giving decision support regarding standardized dosing regimens.
Step one, allows and encouraged patients to take an active role in their medication in their medical care. Patients should understand more about their medications and take more responsibility for monitoring those medications. Providers have the responsibility to educate the patients or caretakers and make sure they understand their medication regimens. Step two; the multi-disciplinary team should inform the patients or caretaker the risks, contraindications and possible side effect of each medication and what to do if they experience a side effect. The IOM recommends that the FDA, the national Library of Medicine and other government agencies work together to standardize and improve the medication leaflet provided b pharmacy, making more and better drug information available over the internet and develop a 24-hour national telephone helpline that offers consumers easy access to drug information (Brennan 2006).
Step three; to reduce errors is utilizing the use of information technology in prescribing and dispensing medications. By using point-of-care references information, prescribers can detail information about the
particular drugs they prescribe and get help in deciding which medication to prescribe. By writing prescription electronically, doctors and other providers can avoid many of the mistakes that accompany hand written prescription. By typing e-prescription is in the system it will follow the patient from hospital, to doctor’s office to nursing home to pharmacies and where ever the patient goes for health care. This system will avoid many hand-off errors Conclusion
Reducing Medication errors demands the attention and active involvement of everyone. It begins with effective communication to all participants. Reducing errors saves millions of lives, billions of dollars and prevent many pain and suffering. All staffs should be vigilance and be sure to use the safety practice already in place in your facilities. Eliminate distractions while preparing and administering medications.
References
Anderson, P., & Townsend, T., (2013) Medication Errors: Don’t let them happen to you. The American Nurse Today vol; 5(3): pp. 23-28. Brennan, T. A., (2006). The Institute of Medication Report on errors. New English Journal Medicine vol: 342 pp. 1123-1125 Duncan, D., & Mayo, A. M.(2004). Nurse Perception of Medication Errors: What we need to know for patient safety. Journal Nurse Care Vol. 19. (3) pp. 209-217. Joshi, S.M., Nash, D. B., Ranson, S.B. (2006) The healthcare Quality book. Washington, DC health Adminstration press. Institute Of Medicine. (1999). To err is Human: building a safer health system. Washington, DC: National Academic Press. Patel, A., (2009) Tragic Medication Errors in Accidental Abortion and Premature Birth. Roth, M.S., (2007).Examining Medication Errors. Journal of Nursing Vol.pp. 1-7. Stoppler, C.M., (2013).The most common medication Errors Medicine.Net.com 2013. Medication error access @www.josieking.org.