Exploring medication errors and doctors’ and nurses’ perceptions of them in the Paediatric Intensive Care Unit (PICU) By. Administration of medicines is a key element of nursing care. Medication errors within the inpatient setting can have severe consequences on patient harm and prolonging length of stay. The baby girl died five days later. Nurses may not have the authority to make infrastructural changes, but they do have the power to suggest needed changes and take precautions to prevent medication errors, including the following: This includes the patient’s name, age, date of birth, weight, vital signs, allergies, diagnosis, and current lab results. Always ask a colleague or manager for guidance before changing a medication’s dosage or timing. As a nurse, you’re expected to handle everything that comes your way right then and there. 5 True Stories of Nursing Medication Errors. #1 Errors with Medication Handing out the wrong medication to a patient, dispensing an incorrect dosage of medication, or giving a prescription to the wrong patient are some of the errors in this category that might even prove to be fatal to your patients. However, they were able to administer the second dose within the window and the patient was fine. That’s why it’s so crucial to find ways to slow yourself down to make sure you’re doing things correctly. However, due to lack of drug knowledge, overwriting or other causes, care home staff often make medication administration errors. More importantly, there have been few recommendations on the specific safeguards that should be imple-mented throughout the medication-use process to prevent such errors. Whether you’re signing off on orders or administering medications, your patients trust that you’re going to get it right. These include failure to: collaborate with other healthcare team members; clarify interdisciplinary orders; ask for and offer assistance; utilize evidence-based performance guidelines or bundles Insurance Company. is a contributing writer through CopyPress, a content creation company that's working with Berxi to provide the best content around. When she woke up, the patient realized that the nurse had administered the drug via the wrong route. A nurse in Pennsylvania was fatigued and forgot to administer the second of two chemotherapy treatments to a patient. A person can count, validate and verify medications but human errors occur. Your patients’ safety is on the line, and it’s always better to be cautious than to try to figure it out on your own. These are just some of the many possible medication errors that can occur. Medication errors can cause harm due to wrong medication while being under the care of a medical practitioner. Common medication errors yield dangerous consequences in these true stories. PICO (alternately known as PICOT) is a mnemonic used to describe the four elements of a good clinical question.It stands for: P–Patient/Problem I–Intervention C–Comparison O–Outcome. This 2016 case report details a 50-year-old women who was accidentally administered epinephrine instead of midazolam during colonoscopy prep. Once she finished administering the first dosage, she headed home—forgetting about the second dose. Find a system of checks and balances that works for you, and try to go through it every time you need to prescribe or administer medication to a patient. If patients have a barcode armband-use it. … Vecuronium injected instead of Versed. Seventy percent of individuals in the U.S. take at least one medication per day, and more than half of all Americans take two.3 Every day at least one death in the U.S. happens a result of a medication error, and approximately1.3 million people annually are injured due to medication errors. Independent verification of drug doses can prevent mix-ups and misinterpretation. A thesis submitted in partial fulfilment for the requirements for the degree of MSc (by Research) at the University of Central Lancashire . At the time of the report, between 44,000 and 98,000 deaths occurred each year as a result of medical mistakes.1. There are indications from research that 60 percent of patients within hospitals miss their medications at some point. Reflecting on this I realized that the patient wasn’t harmed and we were able to change a hospital wide problem. 4. Updates like these, along with comprehensive nurse CE programs that include healthcare videos, empower nurses and can help prevent medication errors. They are: 1. patient information 2. drug information 3. adequate communication 4. drug packaging, labeling, and nomenclature 5. medication storage, stock, standardizatio… Michael J. Gaunt, PharmD. … As the AHRQ points out, the nurse wasn’t aware that there were any risks in changing the patient’s dosing schedule. Deaths resulting from medical errors are tragic not only for patients and their families, but for the healthcare professionals who are responsible, as an article painfully highlighted about one nurse’s tragic mistake a few years ago. The following are common examples of prescription errors in nursing homes: Providing medication without adequate fluids; Journal of Infusion Nursing… Nurse educators and continuing education providers should include all of these prevention tips, and more, in nurse education programs to help nurses avoid medication errors that could have detrimental or even deadly consequences for patients, and significant consequences for nurses, including disciplinary action, job dismissal, criminal charges, and mental anguish. The majority of medication errors are preventable, and knowing how they happen can teach you what to look out for. 6 Missed Nursing Care Elements of Nursing Care % missed Ambulation three times per day or as order 76% Interdisciplinary rounds 66% Mouth care 64% Medications administered on time 60% Feeding patient when the food is still warm 57% Patient teaching 55% Response to call light within 5 minutes 50% Patient bathing/skin … SBAR (Situation, Background, Assessment, Recommendation) works like this: Communication is vitally important, as it is the root cause of many sentinel events, according to the Joint Commission (TJC).5. … Want Berxi articles delivered straight to your inbox? The error caused mild but reversible damage to the patient’s heart. It’s important to note that one of the main conclusions of the Institute’s report is that the majority of medical errors occur not as a result of incompetence or recklessness on the part of nurses and other healthcare workers, but rather as a result of faulty systems, fragmented processes, and working conditions (e.g., nurses exhausted from working double shifts). We’ll examine different types of medication errors, how they occur, and prevention measures for reducing these errors. Home > Health & Medicine > Nursing Medication Errors: Causes and Reporting. Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention. Her colleague also failed to properly match the drug with the patient’s medication administration record (MAR). They contribute to adverse events that compromise patient safety and result in a large financial burden to the health service. This can include tablets or capsules that carry the instructions not to … While medication errors still rank as the highest cause of medical error, The Joint Commission in 2013 6 reported that alarm fatigue is now a top safety concern and can result in injury and death to patients. Nursing and surgical groups recommend that each member of ... mental slips or selection errors when grabbing a vial of medication. Accurate documentation is essential and should include accurate recording of the drug information, the name of the drug, the dose, route, time, patient response, and any refusal of the drug by the patient. As many as 400,000 Americans succumb to medical errors annually. For example OTC drugs containing acetaminophen when administered in wrong dosage can increase risks of liver damage. The “SBAR” method can help alleviate miscommunications. Medication math errors and the nursing student. However, it wasn’t until after she asked the staff about it that they acknowledged an error had been made. The prevention of medication errors, which can happen at every stage of the medication … According to psychologists, errors may be classified as ‘mistakes’ (knowledge-based or rule-based errors), ‘slips’ (observable action-based errors such as the slip of pen or technical error) or ‘lapses’ (non-observable memory-based errors); a slip or lapse occurs when the action conducted is not what was intended (Reason,1990, p54), for example… So throughout this essay I will be evaluating and highlighting the learning that took place whilst on placement at a day unit. Dual scales contribute to a fatal error In an error resulting in a patient's death, a nurse confused two dosing scales on a plastic oral liquid dosing cup and incorrectly measured a dose of morphine sulfate oral solution 20 mg/mL for an opioid-naive hospice patient. If you see that look-alike or sound-alike medications are stored next to each other, ask your supervisor to correct the problem, emphasizing the increased risk of medication errors. The total cost of these errors, including lost income and productivity, disability, and the expense of additional care, is estimated at between $17 billion and $29 billion per year. When in doubt, don’t forget that you can always ask the patients themselves. Even if you’re slammed with things to do, remember to slow down and pay attention to what you’re doing. There are many types of medical errors, and they can occur anywhere in the healthcare system-from hospitals, to nursing homes, to pharmacies. We’ve highlighted the specific medication error in each case study, how it happened, and what you should take away from these stories to avoid making similar mistakes. Medication errors, child, pediatric nursing, reporting ABSTRACT Objective The aim of this study was to determine the perspective of pediatric nurses regarding the causes, reporting, and prevention of medication errors. It was later discovered that the patient had received his evening dose later than usual, at 10 p.m.—so he ended up taking two doses six hours apart instead of 12 hours apart. Specifically, the nurse who signed off on the medication put the order on the wrong resident’s MAR. Over-the-counter (OTC) drugs are the most common example of medication error (Porche€ˆ, 2008). No one avoids this issue. Immediately, the patient felt severe, crushing pain flow through her body that caused her to pass out. Two Examples of Name-Related Medication Errors. To help you, we found five real-life medication error case studies that involved nurses. According to the Agency for Healthcare Research and Quality (AHRQ), which published the case study, the patient was found to have “severe QTc prolongation on his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal arrhythmia.” As a result, they had to postpone his surgery until his QTc returned to its regular level. Since this incident, the drug manufacturer now uses larger font sizes, tear-off cautionary labels, and different colors to distinguish drug doses.6 Medications often look alike and sound alike-this can be a source of errors. Image courtesy of Unsplash.com/Thought Catalog, The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. In fact, adverse drug events account for almost 700,000 ER visits and 100,000 hospitalizations every year. Every day some 7000 doses of medication are administered in a typical NHS hospital (Audit Commission 2002). Setting Many people find that it helps them clarify their question, which in … Moon, A. Training should include medication-related policies, procedures, and protocols. For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses. CAUSES OF MEDICATION ERRORS. Using PICO to Formulate Clinical Questions . Chemotherapy mix-up between eribulin and epirubicin. We will write a custom essay specifically for you for only $16.05 $11/page Learn more. In many cases, these errors can lead to medical malpractice claims made against individual practitioners or even against whole care teams. You could also ask colleagues to check your calculations and offer to do the same for them. But medication errors do happen. Copyright © 2020 Medcom, Inc.      All Rights Reserved. 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