Developing a Health Care - Assessment 2-1

1 Medication Errors Developing a Health Care Perspective Applying Research Skills 2 Medication Errors Health care organizations are facing many obstacles as changes are taking place in the way nursing staff must care for patients. Patient care is more based off of patient satisfaction survey’s and providing enough documentation in the unfortunate chance they are taken to court. As nurses are spending more time on the computer documenting than at the bedside, patient safety can be decreased. As a nurse I have seen medication errors with patients. I have seen providers prescribe medications patients are allergic to. It is then the pharmacist and the nurse’s job to notice the error and contact the provider. However, this conversation does not always end well. I have seen nurses not do the math correctly when drawing up medications and then having to contact the provider about their mistake. Although these situations could end badly, I had my own experience with a medication error which has developed a passion on the importance of medication safety. I was in the emergency room for severe abdominal pain. Morphine was listed under my allergies list in my electronic medical record from a previous surgery where it was found morphine causes me to stop breathing completely. The nurse went to the doctor to get me some pain medication. The doctor put an order in for morphine, the nurse drew up the Morphine came in my room and just told me she was giving me something for pain. As a certified nursing assistant that previously worked in this emergency department, I had trust in this nurse and did not ask what she was giving me. Next thing I knew, I woke up with eight nursing personnel and doctors around me. I was given Narcan to counteract the Morphine. Had the doctor looked at my allergy list, he would not have prescribed Morphine. Also, had the nurse checked my allergies, asked if I had an allergy to Morphine, scanned my armband and the medication, she would have been flagged in the computer system not to administer the medication. MEDICATION ERRORS 3 Academic Peer-Reviewed Journal Articles While using Capella University Library’s journal search, I searched for peer-reviewed articles through the database ProQuest. I used the following keywords; medication errors, patient safety and medication administration errors. I used the advanced search to limit the articles to those published within the last five years. Credibility of Journal Articles I selected peer-reviewed journals that were published within the last five years to provide credibility. I confirmed that the journals stated facts about patient safety and and medication safety and solutions. I also confirmed the credentials of the authors of the journal articles. Annotated Bibliography Geneva: World Health Organization. (2016). Medication Errors: Technical Series on Safer Primary Care. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf. In this article, the World Health Organization (WHO) states that it is hard to determine medication error statistics as there are varying definitions of a medication error. Medication errors consist of; adverse drug reactions, drug-drug interactions, lack of efficiency and patient incompliance. WHO states there are many categories of causes of medication errors. These causes according to WHO that involve healthcare professionals are; inadequate knowledge of the patient, drug or perception of risk, overworked or fatigued health care workers, poor communication between health care professionals and the patient, distractions, insufficient resources. Other factors that can cause medication errors are similar names of medications, and repetitive systems. The repetitive systems cause health care professionals to go through the motions which eventually leads to MEDICATION ERRORS 4 medication errors. The main solution discussed is medication review and reconciliation. This is when the nurse or pharmacist goes through the medication list with the patient. They remove any duplicate medications and go through any allergies from medications. This updates their medication list help with future hospitalizations and prevent future possibilities for medication errors. Nanji, K. C., Patel, A., Shaikh, S., Seger, D. L., & Bates, D. W. (2016). Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology,124(1), 25-34. doi:10.1097/aln.0000000000000904 In this journal, the authors discuss how in perioperative medicine, medication errors can easily happen. This is because they bypass most of the safety checks. Safety checks such as; pharmacist approving provider medication orders along with any contraindications with any of the patients’ allergies, also verifying the correct dose per kilogram of the patient. High stress and the time-sensitive schedule to get the patient in the operating room can cause even more medication errors. The authors also stated that medication administration errors are the most cited critical incidents in anesthesia. Solutions to these errors are scanning barcodes of medications and patient arm bands. Although most preoperative and operating room departments do not have the capability of barcode scanning due to the fast paced nursing environment. I worked in periop as a registered nurse and have seen this first hand and how easy it can be to have a medication error. Most medications are documented in the patients chart after the patient is already out of the nurse’s care and in the operating room. MEDICATION ERRORS 5 Rash-Foanio, C., Galanter, W., Bryson, M., Falck, S., Liu, K. L., Schiff, G. D., Vaida, A., & Lambert, B. L. (2017). Automated detection of look-alike/sound-alike medication errors. American journal of health-system pharmacy: AJHP: official journal of the American Society of Health-System Pharmacists, 74(7), 521–527. https://doi.org/10.2146/ajhp150690 This journal article discusses the potential medication errors due to look-alike/soundalike medications. It states the example of cycloserine being ordered but the order was meant to be cyclosporine. The solution for this is an automated system in the electronic medical record program to flag a potential error. The medication must be justified by a correct diagnosis found in the patients’ chart. Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication Errors. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/. This article explains that as there are many different types of medication, such as herbs, supplements, vitamins, lotions, essential oils and prescriptions, this can lead to a medication error. Not to mention the high risk of interactions some of these medications have with others. It is stated that 7,000-9,000 people die from a medication error. This does not include all those that have an adverse reaction to a medication or a complication from a medication. About half of medication errors are due to ordering errors. Only about 30% to 70% of ordering errors are identified. These errors are usually the provider writing the wrong medication, route, dose or frequency. Almost all cases of medication errors were preventable. About 75% of medication errors are due to distractions. Many medication errors used to occur due to illegible writing. Thankfully, most prescriptions are electronically submitted. Unclear medication dose instructions can cause a medication MEDICATION ERRORS error at home if the patient was not sure on the frequency of the prescription. Also, if unapproved abbreviations are used in the instructions, it can cause an error. Medication errors can be avoided if the healthcare team follows the rights of medication administration. These rights are, right drug, right patient, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right drug interaction and evaluation and finally, right education and information. 6 Running head: MEDICATION ERRORS 7 References Geneva: World Health Organization. (2016). Medication Errors: Technical Series on Safer Primary Care. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf. Nanji, K. C., Patel, A., Shaikh, S., Seger, D. L., & Bates, D. W. (2016). Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology,124(1), 25-34. doi:10.1097/aln.0000000000000904 Rash-Foanio, C., Galanter, W., Bryson, M., Falck, S., Liu, K. L., Schiff, G. D., Vaida, A., & Lambert, B. L. (2017). Automated detection of look-alike/sound-alike medication errors. American journal of health-system pharmacy: AJHP: official journal of the American Society of Health-System Pharmacists, 74(7), 521–527. https://doi.org/10.2146/ajhp150690 Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication Errors. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/.