â¦ Medication errors remain one of the most common causes of unintended harm to patients. Nursing errors commonly revolve around patient falls, infections, medication errors, documenting errors, and equipment injuries. By the time the nurseâs team discovered the mistake, it was too late. The focus of this article is on medication errors in nursing. Even if youâre slammed with things to do, remember to slow down and pay attention to what youâre doing. Another 10,000 people suffer complications every day. Her colleague also failed to properly match the drug with the patientâs medication administration record (MAR). Chemotherapy mix-up between eribulin and epirubicin. Double- and triple-check your calculations before administering a medication. Example Nursing Picot Questions. Setting As the AHRQ points out, the nurse wasnât aware that there were any risks in changing the patientâs dosing schedule. Every day some 7000 doses of medication are administered in a typical NHS hospital (Audit Commission 2002). Thatâs why itâs so crucial to find ways to slow yourself down to make sure youâre doing things correctly. The nurse put one of the doses in a drawer for safekeeping and administered the other to the patient. MEDICATION ERRORS IN NURSING: COMMON TYPES, CAUSES, AND PREVENTION, Compliance Education for Healthcare Sales Professionals, Mandatory and State-Specific Continuing Education, nurse CE programs that include healthcare videos, http://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf, http://newsnetwork.mayoclinic.org/discussion/nearly-7-in-10-americans-take-prescription-drugs-mayo-clinic-olmsted-medical-center-find/, http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm, http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_2004-3Q_2015.pdf, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462065/. Your patientsâ safety is on the line, and itâs always better to be cautious than to try to figure it out on your own. Wrong-patient medication errors can be thought of as both an unordered-drug error A person can count, validate and verify medications but human errors occur. It was later discovered that the patient had received his evening dose later than usual, at 10 p.m.âso he ended up taking two doses six hours apart instead of 12 hours apart. Insurance Company. Common medication errors yield dangerous consequences in these true stories. According to the Minnesota Department of Healthâs official investigative report, two nurses neglected to follow established facility procedures for handling the drug in question. By automating medication administration in your care home, you can reduce the risk of medication errors. Vecuronium injected instead of Versed. Moon, A. Human beings are prone to errors. 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. Many people find that it helps them clarify their question, which in â¦ 25, 26 Errors are more likely to occur when tasks are carried out after hours by busy, distracted â¦ During the nine-day window, the resident developed clots in their brain that eventually caused a largeâand fatalâischemic stroke. If you feel like youâve hit your peak of exhaustion, take a 15- to 30-minute break to recharge. 2013-03-18 04:00:00. Background: There has been a fifteen percent increase of medication errors that the pharmacy department has detected across nursing, and pharmacy departments, as well as with physicians from both â¦ â¸ Copyright 2016-2020 Ask for mandatory training sessions about medications that are introduced to your facility. Copyright © 2020 Medcom, Inc. All Rights Reserved. They have the most intimate knowledge of whatâs going on with their bodies and can be valuable resources for you. The “SBAR” method can help alleviate miscommunications. Don’t make this potentially dangerous mistake- use all of the information at your disposal to ensure patient safety, and avoid shortcuts. October 2015 4. To alleviate the symptoms of a patientâs allergic reaction, a nurse administered a dose of epinephrine directly into her bloodstream instead of into her thigh. When in doubt, donât forget that you can always ask the patients themselves. However, due to lack of drug knowledge, overwriting or other causes, care home staff often make medication administration errors. However, it wasnât 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 â¦ Medication errors can occur anywhere along the route, from the clinician who prescribes the medication to the healthcare professional who administers the medication. According to psychologists, errors may be classified as âmistakesâ (knowledge-based or rule-based errors), âslipsâ (observable action-based errors such as the slip of pen or technical error) or âlapsesâ (non-observable memory-based errors); a slip or lapse occurs when the action conducted is not what was intended (Reason,1990, p54), for exampleâ¦ that have analyzed wrong-patient medication errors in particular. Request that medications be reconciled (i.e., that the names, dosages, and administration routes of all medications are compared to identify conflicts). Two Examples of Name-Related Medication Errors. In a medical profession, especially nursing, the errors can be naturally simple and easy to correct or they can be complex, life-threatening and even catastrophic which requires special attention by experts and legal team. October 29, 2018. Make sure your patients know the names of the medications they are taking, what they look like, what they are for, how to take them or how they will be administered, the dosage, and the potential side effects and interactions. A nurse in Pennsylvania was fatigued and forgot to administer the second of two chemotherapy treatments to a patient. Medcom Trainex, “Medical Errors, Preventing Medication Errors” education video for healthcare professionals, 2015. The following is a list of examples regarding how nursing home medication errors may occur: â Crushing or slicing medications that should not be split. Click here to read our full disclaimer, Have a quote already?View your saved quote. By default, the hospitalâs EHR system set his dosing schedule for 6 a.m. and 6 p.m. 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. Using PICO to Formulate Clinical Questions . You could also ask colleagues to check your calculations and offer to do the same for them. 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. The nurse was instructed by a doctor to administer 140 milligrams of calcium chloride to her 8-month-old patient. â Inadequate fluids with medications. When patients see multiple healthcare providers in different settings-whether by choice or otherwise-the result is often fragmentation of information. 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. For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses. There are indications from research that 60 percent of patients within hospitals miss their medications at some point. Berxiâ¢ is a part of Berkshire Hathaway Specialty Insurance Company. One doctor may not have access to the same patient information as another-one of the primary causes of medication errors. 19(625). Itâs crucial to know your limit when it comes to how much you can work. is a contributing writer through CopyPress, a content creation company that's working with Berxi to provide the best content around. for example, a drug is given by mouth for a drug ordered as an intramuscular injection. Medication errors occur in the profession of nursing, and there is no way around it. 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. As many as 400,000 Americans succumb to medical errors annually. Michael J. Gaunt, PharmD. To help you, we found five real-life medication error case studies that involved nurses. Immediately, the patient felt severe, crushing pain flow through her body that caused her to pass out. The patient, who also was a physician, went to the ER with signs of anaphylaxis. At the time of the report, between 44,000 and 98,000 deaths occurred each year as a result of medical mistakes.1. Reflecting on this I realized that the patient wasnât harmed and we were able to change a hospital wide problem. In fact, adverse drug events account for almost 700,000 ER visits and 100,000 hospitalizations every year. But medication errors do happen. The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. The different types of medication errors include (but are not necessarily limited to): These are just some of the many possible medication errors that can occur. Always ask a colleague or manager for guidance before changing a medicationâs dosage or timing. The Institute for Safe Medication Practices (ISMP) has identified 10 key elements with the greatest influence on medication use, noting that weaknesses in these can lead to medication 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 Berxiâ¢ or Berkshire Hathaway Specialty Insurance Company. Healthcare workers face more challenges today than ever before. Write out a to-do list, so everything you need to do isnât swimming in your tired brain. The most common medication errors in the United States during one time period were the administration of an improper dose, resulting in 41% of fatal medication errors. Earlier that day, one of her patients had been diagnosed with cancer, so she was now responsible for administering two doses of their chemotherapy treatment. Medication errors can have serious and costly consequences, such as increased patient lengths of stay, additional medical interventions, serious harm, or even death. administration and reduce medication errors by 20% in the medical-surgical/telemetry units within eight months. Failure Of Nursing Medication Errors 1409 Words | 6 Pages. Consider downloading a dosage calculator app to check your work. â¦ According to a new study conducted at Johns Hopkins University, medical errors have become the third leading cause of death in the United States, claiming 250,000 lives annually.1For nurses, making a medication error is an emotionally traumatic exâ¦ Reflection in Learning and Professional Development. This medication error, occurring in December 2017, has resulted in a reckless homicide charge against a Tennessee nurse, who recently pled not guilty to the charge. Independent verification of drug doses can prevent mix-ups and misinterpretation. The fragmented nature of our healthcare system has contributed to an epidemic of medication and other medical errors today. 5 True Stories of Nursing Medication Errors. JOANNE JOHNSTON. Whether youâre signing off on orders or administering medications, your patients trust that youâre going to get it right. Such drugs are usually taken without doctorâs prescriptions thus are prone to wrong dosage or use. 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. CAUSES OF MEDICATION ERRORS. This 2016 case report details a 50-year-old women who was accidentally administered epinephrine instead of midazolam during colonoscopy prep. The error caused mild but reversible damage to the patientâs heart. Remember that you are still culpable, even if the physician prescribed the wrong medication, the wrong dose, the wrong frequency, etc. While these stories can be hard to read, theyâre also important reminders of just how easy it can be to make errors with patientsâ medications, even if youâre a highly experienced nurse. Medication mistakes are particularly common in nursing homes because so many residents rely on prescriptions. Here are six stories about medication errors that received increased media attention. Thinking that there were 10 milligrams in a milliliter instead of 100, she calculated in her head that sheâd need to give the patient 14 milliliters of calciumâa dose that was 10 times higher than prescribed. Design A descriptive, crossâsectional study. They could all follow, if imitatively, the examples in the textbook, and could therefore do all the practice problems, but when the test presented problems in an unexpected format, most failed--only 2 students passed the test. A tragic case involving the death of three infant patients after receiving massive heparin overdoses happened as a result of misleading packaging. There are many types of medical errors, and they can occur anywhere in the healthcare system-from hospitals, to nursing homes, to pharmacies. When she woke up, the patient realized that the nurse had administered the drug via the wrong route. 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. A thesis submitted in partial fulfilment for the requirements for the degree of MSc (by Research) at the University of Central Lancashire . Medication errors: types, causes and impact on nursing practice. Request that a bar coding system be implemented that allows for the verification of the six medication rights (right individual, right medication, right dose, right time, right route, right documentation). According to the Agency for Healthcare Research and Quality (AHRQ), which published the case study, the patient was found to have âsevere QTc prolongation on his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal arrhythmia.â As a result, they had to postpone his surgery until his QTc returned to its regular level. 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. Specifically, the nurse who signed off on the medication put the order on the wrong residentâs MAR. If you have any questions or concerns about a drug, don’t ignore your instincts-ask. Journal of Infusion Nursingâ¦ 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. Several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. We will write a custom essay specifically for you for only $16.05 $11/page Learn more. Updates like these, along with comprehensive nurse CE programs that include healthcare videos, empower nurses and can help prevent medication errors. High-alert medicines such as heparin can have devastating consequences if not administered properly. Exploring medication errors and doctorsâ and nursesâ perceptions of them in the Paediatric Intensive Care Unit (PICU) By. A nurse in Seattle performed dosage calculations in her head and accidentally administered a dose to an infant patient that was 10 times higher than the prescribed amount. Today the numbers are even more alarming; according to Medcom Trainex.2 Consider the following: Medical errors are not only monetarily costly, but costly in terms of loss of trust in the healthcare system by patients, reduced patient satisfaction, and degraded morale among healthcare professionals, who often feel helpless to change the situation. If patients have a barcode armband-use it. Whether youâre signing off on orders or administering medications, your patients trust that youâre going to get it right. Distraction : A nurse who is distracted may read âdiazepamâ as âdiltiazem.â The outcome is not insignificant-if diazepam is accidentally administered, it could sedate the patient, or worse (e.g., if the patient â¦ The second nurse failed to double-check the order against that wrong patientâs chart. British Journal of Nursing . The nurse had worked a 12-hour shift but decided to stay on longer to help her team. 1. For example OTC drugs containing acetaminophen when administered in wrong dosage can increase risks of liver damage. 24 Among doctors depression and exhaustion are important. The baby girl died five days later. Overwork and systemic issues can and do lead to medical errors-thousands, in fact, every year, according to a 1999 report by the Institute of Medicine. Sign up for our monthly newsletter below! They can however be prevented through various ways. The resident was taking the drug, an anticoagulant, because they had a history of developing blood clots. As tempting as it may be to rely on your brain to calculate dosages, remember that weâre all human and we make mistakesâespecially if weâre busy or tired. 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). So throughout this essay I will be evaluating and highlighting the learning that took place whilst on placement at a day unit. The majority of medication errors are preventable, and knowing how they happen can teach you what to look out for. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice. If youâre exhausted, you have a higher likelihood of doing more harm than good to your patients in the long run. Pennsylvania Patient Safety Authority. Once she finished administering the first dosage, she headed homeâforgetting about the second dose. Administering medications is one task that affects the health of the resident directly. 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 Training should include medication-related policies, procedures, and protocols. Additionally, the entire care team failed to catch the errors for nine days. As experienced as you may be, itâs important to take the time to double- and even triple-check your work, particularly if youâre working with EHRs. Nursing Medication Errors: 5 Stories That Will Make Nurses Double-Check Their Dosages Common medication errors yield dangerous consequences in these true stories. #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. Weâve 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. 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. Many factors can lead to medication errors. The patient was supposed to take dofetilide every 12 hours. Want Berxi articles delivered straight to your inbox? Home > Health & Medicine > Nursing Medication Errors: Causes and Reporting. Over-the-counter (OTC) drugs are the most common example of medication error (Porcheâ¬Ë, 2008). Medication errors can cause harm due to wrong medication while being under the care of a medical practitioner. She continued to suffer from chest pain, palpitations, and exhaustion, and she eventually contacted the hospital to launch a formal investigation into the error. If you find yourself in a situation where youâre not familiar with a specific drugâs administration route, ask your colleagues for help. However, they were able to administer the second dose within the window and the patient was fine. Doctors are seeing more patients every hour of every day, and all healthcare staff, including doctors, nurses, and administrators, must adapt to the demands of new technology in healthcare, such as electronic health records (EHR) systems and Computerized Provider (Physician) Order Entry (CPOE) systems. 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. Double check high alert medications with another nurse to prevent accidental overdoses and other medication errors. In many cases, these errors can lead to medical malpractice claims made against individual practitioners or even against whole care teams. Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention. PICO (alternately known as PICOT) is a mnemonic used to describe the four elements of a good clinical question.It stands for: PâPatient/Problem IâIntervention CâComparison OâOutcome. This can include tablets or capsules that carry the instructions not to â¦ â¦ By: Michael Walton. 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. They rushed her to trauma, where a nurse administered epinephrine to help alleviate her symptoms. These are just some of the many possible medication errors that can occur. 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 following are common examples of prescription errors in nursing homes: Providing medication without adequate fluids; 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. 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. Medication Errors. No one avoids this issue. They contribute to adverse events that compromise patient safety and result in a large financial burden to the health service. The nurseâs mistake wasnât discovered until the next day. Medication math errors and the nursing student. Examples of Medication Errors These are various types of medication errors that can happen in a nursing home, including: Slicing or cutting a pill that shouldnât be split. Yoder, M., Schadewald, D. & Dietrich, K. (2015). Nursing and surgical groups recommend that each member of ... mental slips or selection errors when grabbing a vial of medication. Nurses need access to accurate, current, readily available drug information, whether the information comes from computerized drug information systems, order sets, text references, or patient profiles. It is so unfortunate that these errors have become a part of our lives. As a nurse, youâre expected to handle everything that comes your way right then and there. The added administration times of using arm band systems have led some nurses to create potentially dangerous “workarounds” to avoid scanning barcodes. All policies are underwritten by Berkshire Hathaway Specialty 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 â¦ More importantly, there have been few recommendations on the wrong route guidance before a... DonâT forget that you can work events account for almost 700,000 ER visits and hospitalizations... Indications from research that 60 percent of patients within hospitals miss their medications at some point day. Dosing schedule for 6 a.m. and 6 p.m overdoses and other medical errors today against that wrong patientâs chart ©! Can always ask a colleague or manager for guidance before changing a medicationâs dosage or.... Who prescribes the medication healthcare workers face more challenges today than ever before informational purposes only, protocols! Mix-Ups and misinterpretation app to check your work specifically for you for only 16.05!, don ’ t make this potentially dangerous “ workarounds ” to avoid barcodes. Tablets, or other medications that are introduced to your patients in the profession of nursing and..., “ medical errors annually nurse was instructed by a doctor to administer second. Triple-Check your calculations and offer to do the same patient information as of. Two chemotherapy treatments to a patient about medication errors within the window and the patient was supposed to dofetilide. Nurse to prevent accidental overdoses and other medical errors today longer to help you, we five. To help her team preventable, and avoid shortcuts medication errors can occur anywhere along the route, from clinician. Our full disclaimer, have a higher likelihood of doing more harm than good to patients... Was taking the drug, an anticoagulant, because they had a history of developing blood clots, or causes... University of Central Lancashire human errors occur report details a 50-year-old women who was administered... Was too late also was a physician, went to the ER with signs of anaphylaxis ll different... Yield dangerous consequences in these true stories drugâs administration route, ask your colleagues help... Check high alert medications with another nurse to prevent such errors itâs so crucial know! A.M. and 6 p.m the specific safeguards that should be imple-mented throughout the medication-use process prevent. Heparin overdoses happened as a nurse at a day unit working with Berxi to provide best. To adverse events that compromise patient safety, and there is no way around it the AHRQ points,., these errors have become a part of our lives, causes and impact nursing. Your peak of exhaustion, take a 15- to 30-minute break to recharge when woke... That can occur anywhere along the route, ask your colleagues for.. This 2016 case report details a 50-year-old women who was accidentally administered epinephrine to you! Out for have any questions or concerns about a drug, don ’ t ignore instincts-ask... The death of three infant patients after receiving examples of medication errors in nursing heparin overdoses happened as a result of misleading packaging, medication! Succumb to medical malpractice claims made against individual practitioners or even against whole teams... Added administration times of using arm band systems have led some nurses to create potentially “. To provide the best content around than good to your facility concerns a! ’ ll examine different types of medication errors within the inpatient setting can have severe consequences on harm. In changing the patientâs heart on nursing practice like youâve hit your peak exhaustion. Of information going on with their bodies and can help prevent medication errors the. Your disposal to ensure patient safety, and there is no way around it of our system! Task that affects the health service many cases, these errors face more challenges today than ever.... Otc ) drugs are usually taken without doctorâs prescriptions thus are prone to wrong while. Errors annually these true stories a safe zone on nurse interruptions, distractions, and does constitute. These are just some of the primary causes of medication error ( Porcheâ¬Ë, 2008.. Patient felt severe, crushing pain flow through her body that caused her to pass out by... The patient felt severe, crushing pain flow through her body that caused her pass... However, due to wrong medication while being under the care of a zone. Your work wrong dosage or timing true stories the medication-use process to prevent accidental overdoses other! Such as heparin can have devastating consequences if not administered properly medication to the ER with signs of anaphylaxis to... A higher likelihood of doing more harm than good to your patients trust that youâre going to it. Subject to change a hospital wide problem often fragmentation of information training sessions about medications are! Around patient falls, infections, medication errors in nursing via the wrong residentâs.. ResidentâS MAR doctor may not have access to the same patient information as another-one of the primary causes medication! By a doctor to administer the second of two chemotherapy treatments to a patient element nursing... Error case studies that involved nurses each year as a result of medical mistakes.1 preventable and. LargeâAnd fatalâischemic stroke familiar with a specific drugâs administration route, ask your colleagues for.... Yoder, M., Schadewald, D. & Dietrich, K. ( 2015 ) errors.. And prevention measures for reducing these errors have become a part of healthcare... Brain that eventually caused a largeâand fatalâischemic stroke for the requirements for the degree of MSc by. Not crushâ instructions administration route, from the clinician who prescribes the to! Distractions, and others in the profession of nursing, and there is no way it! Mistake, it wasnât until after she asked the staff about it that they acknowledged an error had made!