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Preventing Medication Error in Nursing 8

Preventing Medication Error in Nursing

Tredia Pereira

College of Nursing, Resurrection University

NUR 4642- Professional Role Transition

Professor Brandon Hauer

March 14, 2021

Preventing Medication Error in Nursing

A medication error is defined as any preventable event by the healthcare professional that may cause or lead to inappropriate medication use harm the patient according to the National Coordinating Council for Medication Error Reporting and Prevention (Center for Drug Evaluation and Research, 2019). Unfortunately, medication errors happen frequently, and their type and frequency vary in hospitals and nursing homes, and it can lead to serious injuries or even deaths. It can occur from the prescribing the medication stage to the administering stage, and although most of it does not end up in a patient’s death, it is a common problem in the healthcare world. The adverse events and errors committed by health care professionals pose a threat to patient safety and may have minor or severe consequences depending on the type of medication error committed. Because of how important it is, patient safety is now a health policy (Asensi-Vicente et al., 2018).

On the telemetry floor, a medication error prevention is pertinent because some of the patients that get admitted to the floor come with a wide range of diseases that could require multiple medications being prescribed. Their medication list has sometimes six to ten medications and nurses on the floor have up to five patients per shift. It is very easy to make a mistake by selecting the wrong patient and withdrawing the wrong medication and that almost happened to one of the nurses I was shadowing.

One of the nurses on the unit supported the topic and expressed how relevant the topic is to the unit because it is very easy to make a mistake if you are overwhelmed by your patients’ needs especially since they all have different needs, and some are more difficult than others.

Preventing medication errors on the floor not only will help keep the patients safe, but it will also prevent the nurses from getting in trouble because medication error is a serious issue in the healthcare world. Taking extra precautions on the unit can also increase a sense of security among the patients and help decrease their fear of not receiving the appropriate care. Adding preventive measures can also decrease patients’ anxiety and uncertainty due to them feeling more secure and protected by specific and intentional safety measures put into place to better the care they receive.

Literature Review of the problem

Medication errors remain the eighth leading cause of amenable and preventable death in the United States of America (USA), causing about 225,000 deaths each year. According to various studies on drug-related hospital admissions, five percent to six percent of all hospitalizations are due to medication-related problems. Reasons or events that can lead to medication errors include patients commonly receiving new drugs or having alternate drugs due to drug formularies limitations which could limit to certain medications during the hospitalization. In addition, the lack of communication, understanding, and collaboration among healthcare providers is a significant factor in preventing medication errors in hospitals (Almalki et al., 2021).. In this meta-analysis, the authors found a significant variation in the reported rates of medication errors in different hospitals in Saudi Arabia. The integrated medication error rate in Saudi Arabia hospitals was estimated to be 44.4% which is very high and shows how often it does happen. Furthermore, it was found that the most frequently reported category of medication errors according to medication-use process stages is in the medication-prescribing stage which is very concerning and puts patients in danger.

Waaseth et al. composed a study on medication errors and patients’ study in a Norwegian hospital and discovered that medication errors are associated with prolonged hospitalizations at higher health costs and represent increased burdens for patients and public healthcare services. (Waaseth et al, 2019). Medication error is punitive and because of that, a lot of healthcare workers do not report it when it happens in fear of losing their job which results in a lot of medication error not being reported. The authors discovered that nurses, more frequently than doctors, reported medication errors and discussed reported errors at staff meetings while doctors preferred to solve the problem directly by writing a new medication order rather than writing a report(Waaseth et al, 2019). They discussed that the aim of medication error reporting is to learn from our mistakes and to continuously improve treatment and ultimately treatment outcome. Reporting medication errors improves the safety of future patients and helps prevent serious injuries that could happen from it.

Literature review of the solution

According to Alomari et al. (2018), all nurses need to be familiar with various strategies to prevent or reduce the potential risk for malpractice. The first strategy is to ensure that they are using the five drug administration rights and that institutional policies regarding drug transcription are adhered to. It is important to make sure that the right medication is prescribed to the right patient in the right dose, in the right way, and calculated correctly. The second strategy is to document everything correctly while making sure that the documentation is easy to read and includes a proper record of the drug administered. Proper documentation about the drug plays a huge role in preventing medication errors. A very important step before medication administration that a lot of healthcare professional skip is reading the prescription label and checking the drug expiration date because sometimes it is possible that a drug expired already and nobody noticed it.

Rodziewicz & Hipskind (2018) stated that malpractices are very common and that healthcare providers should prioritize avoiding them at any cost. Nurses spend a lot of time with their patients and have a great responsibility to prevent malpractice. When administrating medications, nurses need to use some important identifiers such as the patient name, the right medication, right dose, and right route to ensure that so that the patient is receiving the correct medication.

According to Gorgich et al. (2016), to prevent this frequent error, medical professionals should first identify the cause. The survey included information about strategies that are effective in preventing frequent outbreaks. According to nurses and nursing students in the study, several factors influence the frequency of malpractice. Based on the data collected, the 5 most causes of frequent medication error were fatigue, increased patient ratio, unreadable doctor’s orders, short staffing, and increased distractions.

Implementation

Medical malpractice has become one of the most dangerous aspects of treatment in hospitals and primary care environments. Patients are at risk of seemingly simple and preventable medication errors. Studies have shown that most malpractices are due to understaffed or overworked nurses, improper prescribing of medications, or improper medications. Failure to communicate between interdisciplinary teams compromises patient safety. As these instances begin to grow exponentially, healthcare professionals need to work together with solutions that can be used anywhere. The more information and research is done, the more we can work towards the overall goal of patient safety with medication.

Patients safety is critical in planning care and medication errors can ultimately be reduced by educating the inter-disciplinary team. The project will address the issue by organizing more in-service on the unit regarding medication administration, another one for doctors regarding medication prescription and assessing if there is a decrease in the medication error rate after the first three months of implementing the in-service. Also, increasing interaction between healthcare providers and nurses, and better-educating patients on their current medication before they return home is important. There are no guaranteed solutions that can immediately fix the problem of medication error, because it will take a progressive collective work from the healthcare team to reduce its rate. Patients can be kept safer if healthcare professionals on the unit work as a team and the best way to create a productive and positive environment is trough constant education . The more empowered and collaborative the nursing team is, the safer the patients will be. The in-service will take place every three months, and members of the healthcare team will provide their feedback and also give suggestions on how to better tackle the issue.

It is important for healthcare professionals to maintain close communication between nurses, doctors, and other members of the interdisciplinary team because the stronger the communication, the safer and healthier the patient. Malpractice is the most harmful, costly and have a direct impact on patient safety. To address this persistent problem, there is the need to improve overall communication, provide more accurate treatment instructions and monitoring, and educating patients as well on their treatment plan.

References

Almalki, Z. S., Alqahtani, N., Salway, N. T., Alharbi, M. M., Alqahtani, A., Alotaibi, N., … Alshammari, T. (2021). Evaluation of medication error rates in Saudi Arabia. Medicine, 100(9).

Alomari, A., Wilson, V., Solman, A., Bajorek, B., & Tinsley, P. (2018). Pediatric nurses’ perceptions of medication safety and medication error: a mixed-methods study. Comprehensive Child and adolescent nursing, 41(2), 94-110.

Asensi-Vicente, J., Jiménez-Ruiz, I., & Vizcaya-Moreno, M. F. (2018). Medication errors involving nursing students. Nurse Educator, 43(5).

Center for Drug Evaluation and Research. Working to reduce medication errors. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors.

Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global journal of health science, 8(8), 220.

Kavanagh, C. (2017). Medication governance: preventing errors and promoting patient safety.

British Journal of Nursing, 26(3), 159-165

Rodziewicz, T. L., & Hipskind, J. E. (2018). Medical error prevention.

Waaseth, M., Ademi, A., Fredheim, M., Antonsen, M. A., Brox, N., & Lehnbom, E. C. (2019). Medication Errors and Safety Culture in a Norwegian Hospital. Studies in health technology and informatics, 265, 107–112.