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. Medication errors remain one of the most common causes of unintended harm to patients. 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. 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. The patient was supposed to take dofetilide every 12 hours. 25, 26 Errors are more likely to occur when tasks are carried out after hours by busy, distracted … Nursing errors commonly revolve around patient falls, infections, medication errors, documenting errors, and equipment injuries. Every day some 7000 doses of medication are administered in a typical NHS hospital (Audit Commission 2002). If you have any questions or concerns about a drug, don’t ignore your instincts-ask. 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. The focus of this article is on medication errors in nursing. It is so unfortunate that these errors have become a part of our lives. Here are six stories about medication errors that received increased media attention. While these stories can be hard to read, they’re also important reminders of just how easy it can be to make errors with patients’ medications, even if you’re a highly experienced nurse. 2013-03-18 04:00:00. Want Berxi articles delivered straight to your inbox? Training should include medication-related policies, procedures, and protocols. Medication math errors and the nursing student. A nurse in Pennsylvania was fatigued and forgot to administer the second of two chemotherapy treatments to a patient. 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. All policies are underwritten by Berkshire Hathaway Specialty 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. 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). Medication errors can have serious and costly consequences, such as increased patient lengths of stay, additional medical interventions, serious harm, or even death. JOANNE JOHNSTON. Yoder, M., Schadewald, D. & Dietrich, K. (2015). One doctor may not have access to the same patient information as another-one of the primary causes of medication errors. The prevention of medication errors, which can happen at every stage of the medication … Double- and triple-check your calculations before administering a medication. When patients see multiple healthcare providers in different settings-whether by choice or otherwise-the result is often fragmentation of information. Click here to read our full disclaimer, Have a quote already?View your saved quote. Additionally, the entire care team failed to catch the errors for nine days. A nurse at a Minnesota nursing home transcribed a resident’s medication order on a different person’s chart. Specifically, the nurse who signed off on the medication put the order on the wrong resident’s MAR. 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. The “SBAR” method can help alleviate miscommunications. As many as 400,000 Americans succumb to medical errors annually. In many cases, these errors can lead to medical malpractice claims made against individual practitioners or even against whole care teams. 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. Once she finished administering the first dosage, she headed home—forgetting about the second dose. 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. Consider downloading a dosage calculator app to check your work. A person can count, validate and verify medications but human errors occur. 1. Whether you’re signing off on orders or administering medications, your patients trust that you’re going to get it right. Human beings are prone to errors. Moon, A. 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. The following are common examples of prescription errors in nursing homes: Providing medication without adequate fluids; 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/. Doing more harm than good to your patients trust that you’re going to get it right ask... Mild but reversible damage to the health service was taking the drug via wrong! 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