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Medication Errors Case Study Paper

Medication Errors Case Study Paper

Types of Medication Mistakes

Three people involve in medical specialty, the physician who will order the medical specialty, the druggist who will provide the medical specialty and the nurse who will give the medical specialty. Any errors done by any one of these three people will ensue in medicine mistake. Therefore, there are three chief types of medicine mistakes, the prescribing mistakes, the dispensing mistakes and the administering mistakes.Medication Errors Case Study Paper


Ordering mistakes:

The physicians are responsible for ordering the medical specialties for the patients. There are three types of ordering mistake: utilizing incorrect drug name, incorrect dosage and incorrect dose frequency.

To get down with, it is really common to utilize incorrect drug name as there are new medical specialties come inning the market every twelvemonth. There are more than 17,000 trade and generic name for pharmaceuticals marketed in North America ( Kwabena, 2004 ) .In add-on, the medical specialty dosage and frequency vary from patent to patent for illustration, kids, aged and nephritic patents requires particular attending in composing the dosage. Furthermore, some medical specialties require particular dose tapering before they can be wholly stopped. Furthermore, ciphering the dosage need particular mathematical technique where physicians may non hold the clip and experience to make.Medication Errors Case Study Paper

In interviews done in Australia with 15 physicians who had contributed to a important medicine mistakes, they admitted that the prescribing mistakes was due to faux pass in attending or oversights due to memory failures and 8 mistakes was knowledge- based errors. These errors happen when the physicians are busy, tired or working with unfamiliar patients or patients who have complex status. The Knowledge-based errors were chiefly due to the trouble to entree the drug information, guidelines or protocols. In some instances, junior physicians did n’t inquire aid as they do n’t desire to upset a busy co-worker or they were holding low outlook to acquire aid. This indicates serious communicating jobs in the squad. In add-on, two physicians province that they increase sedation for older patients because they felt pressured by nurses to make that. Furthermore, 10 of the 15 physicians did non recognize that, they caused a medicine mistake until the research squad approached so as the mistakes happened with unfamiliar patients ( Nichols P, 2008 ) .Medication Errors Case Study Paper

Distributing Mistakes:

Distributing medical specialty is the pharmacist duty. Pharmacists are besides responsible for incorporating and measuring the dosage, the path, the frequency and the intervention continuance.

In add-on, the druggist should play a major function in replying all the medicines enquirers by the physicians and the nurses.

In UK and USA survives showed 10 % incidence due to distributing mistakes even in advanced medicine distribution systems. In a survey done in a public pediatric infirmary in Brazil in 2005-2006, a entire rate of more than 10 % dispensing mistakes was found. Mistakes were classified as content mistakes, labeling mistakes and certification mistakes ( Costa LA, 2008 ) .Medication Errors Case Study Paper

The most common content mistakes were the “missing doses” where medical specialty was supply in smaller measure than what was prescribed by the physician. On the other manes the “other labeling errors” which include the illegible name or figure were the most common labeling mistakes. The certification mistakes represent merely 1.7 % of the entire mistakes, 40 % of these mistakes were absent or wrong certification of controlled drugs ( Costa LA, 2008 ) .

Another survey showed that the dispensing mistakes were due to attending faux pass, memory oversights and knowledge-based mistakes. Like the physicians and the nurses, the druggist give grounds of being stressed, tired and busy in making multiple undertakings in the same clip ( Nichols P, 2008 ) .Medication Errors Case Study Paper

Administering Mistakes:

Administering medicines is a nurse ‘s duty, therefore ; administrating mistakes are nurse ‘s errors. It is cardinal for a nurse to recognize the medicine and all the facet related to the medicine such as, the action, side effects readying and there inter action with other medical specialty.

A survey was done in two aged long stay wards in UK psychiatric infirmary, by utilizing direct observation, chart reappraisal and the incidents studies. A head druggist was detecting the modes operand and the PRN ( as required ) medicine disposal at each day-to-day everyday medicine unit of ammunition for over two headboards, than the druggist was look intoning the medicine chart to asses if any mistake has been occurred during the disposal clip. Another druggist was look intoning the chart and entering the medicine mistakes which were recorded in the chart. This druggist did non recognize the consequence of the mistakes recorded by the first druggist. After that the incident study was checked to enter the medicine mistakes which were reported Medication Errors Case Study Paper

during that period. The information was analyses after the experimental period. Administering mistakes were really common, happening in one of four doses. The most common mistakes detected

in this survey were oppressing tablets or opening capsules without the prescribes permission, skip of the dosage without a valid clinical ground, neglecting to sing the medicine chart and giving incorrect medical specialties measure. Furthermore, the experimental survey detected two and a half times the Numbers’s of mistake than the reappraisal of the medicine chart. Furthermore, none of the detected mistakes were reported in the incident coverage system ( Haw, 2007 ) .

Another survey was done in a University infirmary in San Paulo province, Brazil. In this survey, the nurses supervisors were asked to compose down all the questions which were asked to them by the nurses during the survey period and their replies to clear up the uncertainty, than they were asked to compose the beginnings of their information. By analyzing the information collected in this survey, it was found that ; the most common inquiries were about the medicine dilution ( 40.4 % ) , 15.7 % uncertainties were about administrating technique and 11 % uncertainties about the drug interaction. Furthermore the nurse supervisors who are considered as expert and knowing professionals give 35.5 % incorrect or partly right replies. These replies may hold caused inauspicious reaction to the patient. Furthermore, the nurse supervisors ‘ beginnings of replies Medication Errors Case Study Paper

were from their ain cognition, literature and co-workers from other countries. Merely 7.5 % replies were obtained from druggists who suppose to be the first beginning of information, this may be either because of trouble to make them as they are far off from the clinical

pattern or because the nurses did non see them as the best beginning of information about medical specialty ( da Silva DO,2007 ) .

Patient function in placing the mistakes:

Patients are the best perceive r of their attention in the infirmaries. Can the patients and their households identify the jobs, the hurts or the mistakes impacting their attention in the infirmaries? A survey was done in a medicine unit of Boston learning infirmary in USA to reply this inquiry. 228 inmates were interviewed during their hospitalization and than 10 years after their discharge. 62 patients reported that they have incidents or near misses.47 of the incidents reported were medicine related jobs. Half of the incidents were non recorded in the medical record and none were reported in the incident coverage system ( Weingart SN, 2005 ) .Medication Errors Case Study Paper

Schemes to cut down the medicine mistakes:

Hospitals and staffs ( physicians, druggist and nurses ) are responsible for patient safety during prescribing, distributing and administrating medicine.

Hospitals are responsible for supplying safe on the job functions and environment. First of all infirmaries should reconstitute their systems to better the human resorts by increasing the figure of employ and cut downing the deficit of staffs. On the other manus the working hours should be reduced, the nurse to patient ratio should be improved and a 24hour clinical druggist should be present. Than infirmaries should better the human resources degree by

On the other manus, staffs have the major function in cut downing the incident. Following are some stair’s to cut down the medicine mistakes: providing continues developing plans and advancing recycling. The infirmaries should besides supply a clear dilution protocol, up dated literature and a prescribing guideline. Another thing infirmaries should make is supplying an easy entree to internet. Hospitals should besides supply an electronic prescribing system to cut down the incidents happening due to hard script and should see utilizing the unit dose distributing system. Finally, the incidents describing system should be improved in order to promote staffs to describe the incidents.Medication Errors Case Study Paper

Use a personal pharmacopeia with the often used medical specialty and maintain it up to day of the month.
Use a digital contraption with internet service if it is possible.
Be familiar with the medicine, their actions, side effects and inter action with other medicine.
Keep yourself updated by go toing classes and workshops.
Follow the five rights ( right patient, right drug, right dosage, right path and right clip ) and ever look into and dual quench before authorship, providing and giving the medical specialty.
Doctors and nurses should clearly province the patients full name and his figure before composing or giving the medical specialty.
Doctors should compose the intent of the medical specialty in the medicine chart ( with keeping patient confidentiality ) .
Doctors should order medical specialty merely when needed, they should non order medical specialty merely upon patient petition.
Take the allergy history of the drugs from the patient or his household.
Take the history of any herbal therapy used by the patient and be cognizant of the most common herbal drug and their actions and side effects.Medication Errors Case Study Paper
Repeat the verbal order and be cognizant of the “sound alike” drugs particularly when utilizing the phone.
Ask the druggist aid whenever needed as they are the best beginning of information in medicine.
Take proper history when covering with unfamiliar patients.
Be organized and seek non to affect in many undertakings at the same clip.
In instance of any uncertainty take experts sentiment before covering with the medicine.
When covering with any new or unfamiliar medical specialty read about it foremost.
When covering with chronic patient asked about all his medical specialty and if possible ask him to convey all the medical specialty with him.
Good communicating between the wellness squad should be maintain.
Take excess percussion when covering with particular population such as kids, aged and nephritic patient.
Involve the patient and his household in his attention and explicate to him the action and side effects of his medicine.Medication Errors Case Study Paper

Medicine mistakes are one of the most serious facets interfere the patient ‘s safety in the infirmaries. By following the bar Strategies, the physicians, the druggist and the nurses can supply safe medicine disposal to the patient. Hospitals on the other manus, are responsible for supplying safe environment for the staffs to see safe medicine disposal. Finally, the incident coverage system should be improved. It is possible that the fright or the deficiency of consciousness prevents staffs from describing the incidence. Educational plan should supply to promote the staffs to describe the mistakes before the inauspicious reaction can happen.

Patient Falls and Medication Errors

Falls are the 2nd most common inauspicious event within wellness attention establishments following medicine mistakes. and an estimated 30 % of hospital-based falls consequence in serious hurt. The badness of this job led the Joint Commission to do cut downing the hazard of patient hurts from falls a national patient safety end for infirmaries in 2009 ( AHRQ. 2006 ) . Falls are a primal cause of hospital-acquired hurt and often prolong and complicate infirmary corsets and consequence in hapless quality of life. increased costs. and unforeseen admittance to long-run attention installations. Changes in wellness attention funding in the 1990s were accompanied by a assortment of cost-cutting steps in infirmaries across the United States. Common cost-cutting schemes included cut downing the entire figure of nursing hours per patient twenty-four hours and cut downing the per cent um of hours supplied by registered nurses ( RNs ) . the most extremely paid group.Medication Errors Case Study Paper




The decrease in staffing led to widespread concern that patient attention in ague attention scenes would endure. In response to concerns about staffing and quality of attention. the American Nurses Association ( ANA ) launched the Patient Safety and Nursing Quality Initiatives in 1994 to turn to the impact of wellness attention reconstituting on patient attention and nursing. To ease the enterprise. ANA established the National Database of Nursing Quality Indicators ( NDNQI ) in 1997. with two ends: ( 1 ) to develop a database that would back up empirical monitoring of the impact of nurse staffing on patient safety and quality of attention across the state. and ( 2 ) to supply single infirmaries with a quality betterment tool that includes national com parings of nurse staffing and patient results with similar infirmaries ( Hart and Davis. 2010 ) .

Selection Rationale
Patient falls impact infirmaries both financially and in regulative organic structure position. In 2005. in response to upsetting and widely cited findings by the Institute of Medicine about the prevalence of dangerous conditions acquired by patients in U. S. infirmaries. Congress authorized the Centers for Medicare and Medicaid Services ( CMS ) to implement payment alterations designed to promote the bar of such conditions. Under an amendment to the Social Security Act that was enacted on January 1. 2007. the secretary of Health and Human Services was required to place at least two hospital-acquired conditions by October 1. 2007. that were high-cost. high-volume. or both ; that resulted in the assignment of a instance to a higher-paying diagnosis-related group ( DRG ) when they were present as a secondary diagnosing ; and that could moderately be prevented through the application of evidence-based guidelines ( New England Journal of Medicine. 2009 ) .

The CMS worked collaboratively with the Centers for Disease Control and Prevention ( CDC ) and on October 1. 2008. enacted new payment commissariats: Medicare will no longer reimburse infirmaries for a higher-paying DRG when one of eight selected hospital-acquired conditions develops during the infirmary stay. The CMS heralded this move as an attempt to aline fiscal inducements with the quality of attention. thereby advancing both quality and efficiency. Hospital falls and injuries were included as one of the eight conditions that. the CMS argues. “should non happen after admittance to the infirmary. ” Three to 20 % of inmates fall at least one time during their infirmary stay ; these falls result in hurts. increased lengths of stay. malpractice cases. and more than $ 4. 000 in surplus charges per hospitalization. Therefore. infirmary falls represent a major patient-safety job and may perplex a patient’s attention and intervention ( New England Journal of Medicine. 2009 ) . Target Population Medication Errors Case Study Paper

The mark population chosen consists of patients admitted to the medical and surgical floors at two big learning infirmaries. The first infirmary is a 1. 000 bed not-for-profit instruction infirmary located in Dallas. Texas with an mean day-to-day nose count of 917. This organization consists of 12 medical and surgical floors with a entire bed capacity of 428. Each floor consists of the nurse director. registered nurses. certified nursing helpers. and unit secretaries. Patients most often cared for on the medical floors at this installation consist of those enduring from aggravation of chronic clogging pneumonia disease ( COPD ) . pneumonia. diabetes mellitus ( DM ) . intellectual vascular accident ( CVA ) . and sepsis. Patients most often cared for on the surgical floors consist of those mending from orthopedic hurt and/or surgery. stomachache beltway surgery. abdominal exploratory surgery. cerebrovascular surgery. station kidney and liver graft patients. and those patients retrieving from gynecological operations.Medication Errors Case Study Paper

The population of patients being cared for at this infirmary comprise largely of patients 55 old ages and older. Of the 428 patients being cared for on a day-to-day footing at this organization. 15 % of these patients require entire aid. 25 % require extended aid. and 50 % require limited aid. The 2nd infirmary system. North Shore University Health System ( NSUHS ) . is a comprehensive. to the full incorporate. not-for-profit wellness attention system that serves the greater North Shore and Northern Illinois communities. NSUHS includes four infirmaries with 795 configured beds with a sum of medical/surgical configured beds at 495. The mean medical and surgical day-to-day nose count is 103. 9. The medical/surgical tenancy is 62 % of staffed beds on 19 units. Each unit consists of a clinical nurse director. registered nurses. patient attention technicians. and unit concierges.Medication Errors Case Study Paper

The top medical DRG’s include congestive bosom failure ( CHF ) . pneumonia. respiratory. acute myocardial infarction ( AMI ) . and CVA. The top surgical admittance’s include orthopedic joint replacing. general surgery. and spinal surgery. The mean age of patients being cared for in this system is 68. 5 old ages. Of the 495 patients being cared for on the medical and surgical units. at least 50 % require entire aid and 50 % require limited aid. Significance

Patient falls in the infirmary scene are common and may take to negative results such as hurts. drawn-out hospitalization. and legal duty. Falls can besides hold serious effects on a person’s ability to map as a productive member of their household. community. or society. These happenings have long been documented as a important. and potentially inevitable. type of unwanted patient event ( Steven. 2004 ) . Patient falls are the 2nd most common cause of injury in infirmaries and are the taking class of reported incidents in infirmaries impacting about three to 20 % of patients during their hospitalization ( Sutton & A ; ump ; Wallace. 2005 ) . The frequency of patient falls. as recorded in the literature. ranges from 25 % to 89 % of all hospital inauspicious incidents. depending on the patient population studied ( Hitcho. 2004 ) .Medication Errors Case Study Paper

The rates vary from 1. 9 up to 18. 4 falls per 1. 000 patient years depending on organization type. and harmonizing to a survey by the National Council on Aging. 30 % of these incidences result in serious hurt ( Stevens. 2004 ) . Another important effect of falls is that they are expensive and contribute to the increasing wellness attention outgo. An estimation of the mean DRG payment for hurts sustained by a patient falling is $ 25. 643 ( Hart. Chen. Rashidee. and Sanjaya. 2009 ) . This is important in that with the developing ambiance of pay-for-performance. initiated by CMS. infirmaries now have a major pecuniary interest in cut downing the figure of fall-related hurts. The CDC estimates that the cost of autumn hurts will transcend $ 23 billion within the following few old ages ( Tzeng. 2008 ) .Medication Errors Case Study Paper

Malpractice claims due to inauspicious drug events can hold negative effects on the infirmary and the wellness attention suppliers. The infirmary and wellness attention suppliers can hold their repute damaged, 1000s of dollars are spent for the losingss, there is clip lost from work, non to advert the emotional emphasis involved ( Rothschild et. Al, 2002 ) . The cost of preventable medicine mistakes has been estimated between 17 and 29 billion dollars yearly ( Strohecker, 2003 ) . As such, due to these dismaying statistics, this paper focuses on some of the possible hazards of medicine mistakes, and some recommended intercessions that can be implemented to assist control the incidence of medicine mistakes.Medication Errors Case Study Paper

What is a medicine mistake?

A medicine mistake is defined as ” any preventable event that may do or take to inappropriate medicine or patient injury while the medicine is in the control of the wellness attention professional, patient, or consumer ” ( Oren, 2003 ) . The footings inauspicious drug events and medicine mistakes though used interchangeably do non needfully intend the same thing. An inauspicious drug event is an unwanted reaction after a drug disposal that is non needfully caused by the drug. Adverse drug events include inauspicious drug reactions and medicine mistakes. Medication mistakes may take to existent or possible inauspicious events. The possible inauspicious events are frequently termed ” close girls ” . For illustration, if a medicine overdose is administered by chance, it would be a medicine mistake and non described as an inauspicious drug reaction ( Oren, 2003 ) .Medication Errors Case Study Paper

Potential Risks of Medication Mistakes

Many of the factors taking to medication mistake are unluckily human related ( Etchells, et. Al, 2008 ) . A study of 983 nurses working in acute attention infirmaries reported that among the many factors that would lend to medical mistakes, illegible manus written prescriptions, distraction from the environment, exhaustion and emphasis happened to be the most leaden ( Mayo & A ; Duncan, 2004 ) . A survey by Hodgkinson that sought schemes to cut down medicine mistakes cited the most common ground of medicine mistake was due to the deficiency of drug information by the multidisciplinary squad ( 2006 ) . Inexperience and or deficiency of cognition of the drug could take to the doctor telling the incorrect dosage, the druggist falsely blending the medicine with the right concentration, and the nurse administrating the medicine with the incorrect path such as giving an intramuscular injection alternatively of subcutaneously ( Etchells, et. Al, 2008 ) .Medication Errors Case Study Paper

While human mistake is really of import to see, it is every bit of import to analyze the context in which mistakes can happen such as the clinical environment and patient population. The type of clinical scene in a infirmary can be more prone to medicine mistakes than others due to the patient population with regard to the badness of their unwellness, and figure and type of medicines needed to be administered. Critical attention units for illustration, be given to be at a higher hazard for medicine mistakes. Critical attention units provide for really ill patients who need to be attended to without hold, may necessitate consults from assorted suppliers, and have twice every bit many medicines as compared to patients on general medical floors. Patients in intensive attention experience an norm of 1.7 medical mistakes each twenty-four hours. Medicine mistakes are the most common type or mistake and history for 78 per centum of serious medical mistakes in critical attention ( Camire et. Al, 2009 ) Medication Errors Case Study Paper.

In add-on to the patients in critical attention, paediatricss and the aged besides tend to be at high hazard for medicine mistakes since there require many medicines when sick. Pediatric patients in peculiar tend to be really sensitive to most medicines hence the demand to cipher most of their medicine doses by weight ( King, 2003 ) . The least reckoning could take to an inauspicious drug event. Older grownup populations, on the other manus, take many prescription medicines for their chronic unwellnesss which need examination to avoid contraindications ( ANJ, 2009 ) . However, irrespective of whether the patient may be at hazard of sing a medicine mistake or non, all medicine disposal must ideally follow the ” seven rights ” which include ” the right patient, right medicine, right dosage, right clip, right path, right ground, and right certification ” ( Schaeffer, 2009 ) .Medication Errors Case Study Paper

Another factor which may act upon the safety of medicine disposal involves medication rapprochement. When patient ‘s list of place medicines and allergic reactions are non collected upon admittance, a medicine mistake can happen when a medicine being taken on a regular basis at place is non continued during the infirmary stay. If the patient ‘s medicine rapprochement is non complete, the doctor would non hold full cognition of the medicines that the patients would necessitate to be restarted on after being transferred or discharged from the infirmary. At times there may be an inadvertence on the portion of the prescribing physicians where trade name and generic medicine names are concerned. A doctor may besides double order a medicine that the patient may already be taking at place, and at times order an wrong dose ( Landro, 2006 ) .Medication Errors Case Study Paper

In recent times, there have been technological influences in wellness attention, where there has been an attempt to acquire rid of the paper certification but the passage is non that complete. Many infirmaries still document on paper and still making the hazard of medicine mistakes by the usage of mistake prone medicine abbreviations. During written text of written orders, the usage of abbreviations can do mistakes if non interpreted right. In a survey discussed in the Joint Commission Journal on Quality and Patient Safety, medicine mistakes that were reported to the national database made up 5 per centum of all mistakes that occurred as a consequence of wrong reading of abbreviations used during ordering. In the survey, an analysis of 30,000 abbreviations related- medicine mistakes reported to the United States Pharmacopeia ‘s database was made. Most of the mistakes dwelling 81 per centum were made during the authorship of prescriptions. The abbreviation ” QD ” used in topographic point of ” once day-to-day ” was found to hold caused more mistakes ; 43.1 per centum than any other abbreviation. The Joint Commission has a national safety ends report that include a ” do non utilize ” list of abbreviations that infirmaries and other health care organisations can utilize as a mention ( Joint Commission, 2006 )Medication Errors Case Study Paper

Medication Error Risk Reduction Strategies

In add-on to the ” seven rights ” , infirmaries are establishing extra evidence-based patterns. Harmonizing to The Joint Commission Journal on Quality and Patient Safety, the execution of ” six best pattern ” processs for medicine disposal designed by the California Nursing Outcomes Coalition ( CalNOC ) significantly improved truth ( 2009 ) . In this survey, take parting infirmaries showed an 80.5 per centum betterment in attachment to CalNOC best patterns and an 81.4 per centum mark for combined disposal truth and best pattern betterments. The CalNOC six best patterns include: ” compare medicine to medical record, maintain medicine labeled until disposal, look into two signifiers of patient designation, instantly record medicine disposal in the chart, explain the medicine to the patient, and minimise distractions and breaks during the disposal procedure ” ( Joint Commission Journal, 2009 ) .Medication Errors Case Study Paper

Another technological innovation to assist cut down medicine mistakes are the smart extract pumps. These smart pumps have constitutional danger qui vives, clinical reckoners, and drug libraries including information on the standardised concentrations of normally used drugs. Though smart pumps have been designed to forestall errors, it merely works for high qui vive endovenous medicines. In instances where the smart pumps are non used suitably, its intent is non served. In a controlled test survey of smart extract pumps, nurses were found to ” routinely ignore danger qui vives and drug libraries every bit much as 25 per centum of the clip, sometimes administering medicines such as propofol, insulin, and Lipo-Hepin at rates 10 times every bit high as those ordered ” ( Rothschild, 2005 ) . Smart pumps can work exceptionally and prevent mistakes if qui vives are paid attending to used suitably.Medication Errors Case Study Paper


The computerized doctor order entry ( CPOE ) system is another engineering that has been found to significantly diminish the danger of illegible handwritten orders and the demand for written text. Harmonizing to Bates et. Al, out of the about 28 per centum of preventable inauspicious drug events are associated with medicine mistakes, 56 per centum occurred during prescribing ( Bates, et. Al, 1998 ) .The computerized doctor order entry ( CPOE ) , computing machine based system where all orders are electronically written helps to guarantee truth of composing orders. Most of these CPOE are accompanied by a Clinical Decision Support System ( CDSS ) which provides automatic qui vive to prescriber on drugs or doses that are contraindicated with the patient ‘s age, allergic reactions, status, and or diagnosing. Review of a systematic survey by Kaushal et. Al on the effects of CPOE with CDSS showed a considerable diminution in the rates of medicine mistakes ( 2003 ) .

A survey at the Brigham and Women ‘s Hospital in Boston on the consequence of CPOE on bar of serious medicine mistakes showed that utilizing a POE system prevented more than half of the serious medicine mistakes. There was a decrease in all the phases of the procedure ; from telling to distributing to disposal ( Bates, 1998 ) . The good effects of CPOE systems would widen beyond medicine safety and include reduced cost and quality betterment. CPOE hence holds promise as an intercession to better patient safety but would necessitate farther informations of the benefits of costs before execution.Medication Errors Case Study Paper

Bar cryptography is another technological intercession that has been shown to diminish the rate of medicine disposal mistakes. Bar coding can estrange the possibility of nurses administering medicines without holding a documented order. With saloon cryptography, each clip a doctor ordered a medicine, the order is automatically transmitted to the pharmaceutics where a alone saloon codification is generated. After confirmation of the order by the druggist, the labelled medicines are sent to the floor/unit. The nurses who have to administrate the medicine would so hold to scan the saloon codification on the patient designation set against the labels on the medicines for comparing.

Bar cryptography has reduced medicine mistakes by more than 50 per centum, forestalling about 20 inauspicious drug events per twenty-four hours ( Poon, 2005 ) . The Veterans Affairs infirmary led the manner in 1999 establishing a national saloon coding plan. Within a twelvemonth of induction the VA infirmary documented a 24 per centum lessening in the rate of medication-administration mistakes ( Wright et. Al, 2005 ) . Although the ultimate end is to protect patients, saloon cryptography could besides salvage infirmaries tonss of money. The mean inauspicious event costs excess hospital yearss and extra services, non to advert the cost of judicial proceeding. Like every other step there would be disadvantages for utilizing saloon cryptography, but one time more research can demo that the benefits outweigh the costs, more infirmaries can fall in the increasing figure of establishments that have embraced this engineering.Medication Errors Case Study Paper

With medicine mistakes responsible for many lost lives annually, new national patient-safety criterions require infirmaries to hold a compulsory formal medicine rapprochement procedure for every patient admitted into the infirmary. Medication rapprochement would take consequence during the patient ‘s admittance procedure and involves the aggregation of a complete drug and allergy history comparing them with new medicines that he physicians order. This modus operandi has been found to cut down medicine jobs while the patients are admitted and when they are discharged with new drug regimens. This procedure is does non work if attempts are besides non taken to educate patients and households on the importance of keeping a personal up-to-date medicine and allergy list and being able to supply that list in emergent state of affairss ( Landro, 2006 ) .

Drum head

This paper has reviewed research on medicine mistakes in infirmaries with an accent on the prevalence, hazard factors, and schemes to forestall mistakes from happening. Although the immediate cause of medicine mistakes is frequently as the consequence of human mistake, the bulk of mistakes can be attributed to system failures made worse by the increasing complexness of patient attention. A medicine mistake can do annihilating consequences, threaten patient ‘s lives, and impact a supplier ‘s assurance and occupation security. Hospitals besides tend loose tonss of money in malpractice jurisprudence suits. The broad scope of pharmaceutical merchandises and dramatically altering engineering adds to the complex state of affairs. Many schemes including the CPOE and CDSS, smart pumps, and saloon cryptography among other schemes have already been implemented by few infirmaries. Research shows that these schemes that have been implemented aiming the decrease of medicine mistakes have been found to be assuring. However, due to the complexness of patient attention, both human and technological influence may be able to command but ne’er be able to wholly set to decease medicine mistakes.Medication Errors Case Study Paper

The Department of Veteran Affairs late was fined by the Nuclear Regulatory committee due to a serious medical mistake that occurred at one of their installations. The Nuclear Regulatory Commission announced its second-largest mulct in the sum of $ 227,500 after happening the veteran ‘s infirmary in Philadelphia had caused an unprecedented figure of radiation mistakes in handling prostate malignant neoplastic disease patients ( Bogdanich, 2010 ) . Radiation mistakes occurred 15 old ages ago and there were preventive steps established so they would non happen. Federal research workers said the infirmary made important mistakes, mislaying radioactive seeds, in 97 of 116 processes affecting patients with prostatic malignant neoplastic disease from 2002 to 2008. The regulative committee ‘s largest mulct against a medical supplier was 15 old ages ago and totaled $ 280,000. That instance besides involved radiation mistakes ( Bogdanich, 2010 ) . These medical mistakes is a serious phenomenon that surely warrants research.Medication Errors Case Study Paper

This qualitative research survey will analyze the causes of medical mistakes and find if the execution of Continuous Quality Improvement plans has reduced the figure of mistakes found in the Southeast veteran population. This research will be conducted at the William Jennings Bryan Dorn VA Medical Center in Columbia South Carolina by using the VA waiters made available to me by my employee position. The research will analyze instance survives conducted during the clip frame of 2005 – 2009. Other factors such as age, race, gender, medicine and mi-diagnosis will besides be examined to find whether or non there is a cor relativity between the factors and the causes of medical mistakes. My sample will include 20 non-randomly selected instance survives retrieved from Medscape.

Research of Documentation Errors in the Healthcare Profession Research of documentation errors in the health care profession is reviewed in this paper. Many people in the medical field believe errors are a result of using abbreviations in handwritten documentation relating to patients. Accreditation agencies are now composing lists of terms that should not be abbreviated in order to reduce these errors. In this research, the following topics will be discussed: How can eliminating abbreviations reduce error? Should written policies be developed for abbreviation usage?Medication Errors Case Study Paper

If yes, what should the policies contain and if no why? When are abbreviations acceptable, who should use them and why? Have there been enough steps taken to reduce errors? How can eliminating abbreviations reduce error? Patient safety is a common goal in every healthcare institution, thus eliminating abbreviations can reduce life-threatening medical errors. The most common is medication errors. Some abbreviations, symbols, and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm.

They can also delay the start of therapy and waste time spent in clarification. A nurse administering the wrong dosage to a patient if the physician’s handwritten abbreviations are not clear can be lethal. As well, when a patient is transferred from one care provider to another, if the medical records are written with abbreviations this could lead to tragic results. Thus providing clear, communication, abbreviated prescribed prescriptions, reports, and records would greatly reduce medical errors.Medication Errors Case Study Paper

However eliminating all medical abbreviations would reduce errors but if abbreviations were eliminated it would make it very difficult on medical professionals who would have to write out very lengthy medical terms. Since everything in a patient’s medical records must be documented, from s/s (signs and symptoms), to the patient’s medical hx (history), to the final dx (diagnosis) and tx (treatment), it saves the doctors and all other medical personnel a considerable amount of time to use a universally accepted form of medical terminology. According to Dr.Medication Errors Case Study Paper

Darryl S. Rich, “to minimize the potential for error and to maximize patient safety, prescribe rs need to avoid such specifically dangerous abbreviations and phrases. ” (www. joint commission. org/Sentinel Events/Sentinel Event Alert/sea_23. htm) Simple electronic prescription programs can eliminate errors caused by handwriting and transcription errors, assist with dosing, and provided quick access to drug information. (http://jaapa. com/issues/j20040201/articles/0204wmederrors. html) Should written policies be developed for abbreviation usages?

If yes, what should the policies contain? If no, explain. There should be written policies implemented and many organizations are developing written policies stating which abbreviations should not be used and medical professionals are being trained to write legible when using other abbreviations. The written policies are necessary so ensure the safety of all patients. The JCAHO (Joint Commission on Accreditation of Healthcare Organizations) has recently mandated the accredited organizations to develop and enforce a list.

As well as the ISMP (Institute for Safe Medication Practices) are developing written policies stating which abbreviations should not be used. The Joint Commission has come up with a do not use list and the ISPM has a list of error-prone abbreviations, symbols and dose designations. (www. joint commission. org/Patient Safety/Do Not Use List) (www. ismp. org) When are abbreviations acceptable? Who should use them and why? Acceptable abbreviations have been studied and adopted by most medical organizations. JCAHO provides institutions with a list of dangerous abbreviations that should be avoided in clinical documentation.Medication Errors Case Study Paper

In addition, ISMP promotes the consistent application of not using specified abbreviations to prevent errors. The policy recommends not using abbreviations, symbols, and acronyms in medical communication. According to ISMP, abbreviations should never be used in “internal external communication, telephone/verbal prescriptions, computer generated labels, labels for drug storage bins, medication administration records, as well as pharmacy and prescribe r computer order entry screens. ” With the use of these policies and recommendations from these organizations, the abbreviation errors would reduce.

It would also be standardized so all persons in the medical field would understand the abbreviation method. Medical professionals should use abbreviations and acronyms only when they you need them. You should introduce an abbreviation or acronym by putting it in parentheses immediately after the word, it stands for, and you should always confirm that others correctly understand your abbreviation or acronym. (www. boston. com/jobs/healthcare/on call/articles/2008/04/10/in_other_words) According to the information in the online articles, do you think enough steps have been taken to reduce errors?Medication Errors Case Study Paper

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, under prescribing, over prescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, under prescribing and over prescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient’s condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the psychophysiology of the disease.Medication Errors Case Study Paper

Advances in clinical therapeutics have resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased risks. A medication error is an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication. As with the more general term adverse event, the occurrence of an ADE does not necessarily indicate an error or poor quality care. Preventable adverse drug events result from a medication error that reaches the patient and causes any degree of harm. It is generally estimated that about half of ADEs are preventable. Medication errors that do not cause any harm—either because they are intercepted before reaching the patient or because of luck—are often called potential ADEs. An ameliorate ADE is one in which the patient experienced harm from a medication that, while not completely preventable, could have been mitigated. Finally, a certain percentage of patients will experience ADEs even when medications are prescribed and administered appropriately; these are considered adverse drug reactions or non preventable ADEs (and are popularly known as side effects).Medication Errors Case Study Paper

For example, the intravenous anticoagulant heparin is considered one of the highest-risk medications used in the inpatient setting. Safe use of heparin requires weight-based dosing and frequent monitoring of tests of the blood’s clotting ability, in order to avoid either bleeding complications (if the dose is too high) or clotting risks (if the dose is inadequate). If a clinician prescribes an incorrect dose of heparin, that would be considered a medication error (even if a pharmacist detected the mistake before the dose was dispensed). If the incorrect dose was dispensed and administered but the patient experienced no clinical consequences, that would be a potential ADE. If an excessively large dose was administered, the overdose was detected by abnormal lab results, but the patient experienced a bleeding complication due to clinicians failing to respond appropriately, that would be considered an ameliorate ADE (that is, earlier detection could have reduced the level of harm the patient experienced).

Adverse drugs events are one of the most common preventable adverse events in all settings of care, mostly because of the widespread use of prescription and nonprescription medications. Clinicians have access to an armament of more than 10,000 prescription medications, and nearly one-third of adults in the United States take 5 or more medications. Each year, ADEs account for nearly 700,000 emergency department visits and 100,000 hospitalizations. Nearly 5% of hospitalized patients experience an ADE, making them one of the most common types of inpatient errors. Ambulatory patients may experience ADEs at even higher rates, as illustrated by the dramatic increase in deaths due to opioid medications, which has largely taken place outside the hospital. Transitions in care are also a well-documented source of preventable harm related to medications.Medication Errors Case Study Paper

Risk Factors for Adverse Drug Events

There are patient-specific, drug-specific, and clinician-specific risk factors for ADEs. Poly pharmacy—taking more medications than clinically necessary—is likely the strongest risk factor for ADEs. Elderly patients, who take more medications and are more vulnerable to specific medication adverse effects than younger patients, are particularly vulnerable to ADEs. Pediatric patients are also at heightened risk, especially when hospitalized, since many medications for children must be dosed according to their weight. Other well-documented patient-specific risk factors include limited health literacy and numeracy (the ability to use arithmetic operations for daily tasks). It is important to note that in ambulatory care, patient-level risk factors are probably an under recognized source of ADEs. Studies have shown that both caregivers (including parents of sick children) and patients themselves commit medication administration errors at surprisingly high rates.

The Institute for Safe Medication Practices maintains a list of high-alert medications—medications that can cause significant patient harm if used in error. These include medications that have dangerous adverse effects, but also include look-alike and sound-alike medications: those that have similar names and physical appearance but completely different pharmaceutical properties. The Beers criteria, which define certain classes of medications as potentially inappropriate for geriatric patients, have traditionally been used to assess medication safety. However, the newer STOPP criteria (Screening Tool of Older Person’s inappropriate Prescriptions) have been shown to more accurately predict ADEs than the Beers criteria and are therefore likely a better measure of prescribing safety in elderly patients.Medication Errors Case Study Paper

Though there are specific types of medications for which the harm generally outweighs the benefits, such as Benzedrine sedatives in elderly patients, it is now clear that most ADEs are caused by commonly used medications that have risks, but offer significant benefits if used properly. These medications include anti diabetic agents (e.g., insulin), oral anticoagulants (e.g., warfarin), anti platelet agents (such as aspirin and clopping), and opioid pain medications. Together, these four medications account for more than 50% of emergency department visits for ADEs in Medicare patients. Focusing on improving prescribing safety for these useful but higher-risk medications may reduce the burden of ADEs in elderly patients more than focusing on use of potentially inappropriate classes of medications.


The opioid epidemic—which was declared a public health emergency in 2017—has also brought to light the role of clinician-specific and health system factors in medication errors. Opioid prescribing has increased dramatically over the past 15 years, and recent research questions the benefit of this practice. For example, opioid prescribing after dental procedures and low-risk surgical procedures increased sharply between 2004 and 2012, despite lack of evidence for the benefit of opioids in these situations. Another study found wide variation in opioid prescribing practices between physicians in the same specialty. The reasons behind why physicians over prescribe opioids are complex, and they are explored in more detail in a 2016 PSNet Annual Perspective Medication Errors Case Study Paper

Prevention of Adverse Drug Events

The pathway connecting a clinician’s decision to prescribe a medication and the patient actually receiving the medication consists of several steps:

Ordering: the clinician must select the appropriate medication and the dose, frequency, and duration.
Transcribing: in a paper-based system, an intermediary (a clerk in the hospital setting, or a pharmacist or pharmacy technician in the outpatient setting) must read and interpret the prescription correctly.
Dispensing: the pharmacist must check for drug–drug interactions and allergies, then release the appropriate quantity of the medication in the correct form.
Administration: the correct medication must be supplied to the correct patient at the correct time. In hospitals or long-term care settings, this is generally the responsibility of nurses or other trained staff; in ambulatory care the responsibility falls to patients or caregivers.

The widespread use of electronic health records has helped avert errors at the ordering and transcribing stages, but these errors still persist, and studies have found a high rate of medication administration errors in both the inpatient and outpatient settings.

Medication errors
There are different classification for medication errors, here I provide the common classification scheme based on the nature of the error
Prescribing Error
Incorrect drug product selection (based on indications, contraindications, known allergies, existing drug therapy, and other factors), dose, dosage form, quantity, route of administration, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician (or other legitimate prescriber); illegible prescriptions or medication orders that lead to errors.Medication Errors Case Study Paper
Omission error
The failure to administer an ordered dose to a patient before the next scheduled dose or failure to prescribe a drug product that is indicated for the patient. The failure to administer an ordered dose excludes patient’s refusal and clinical decision or other valid reason not to administer.
Wrong time error
Administration of medication outside a predefined time interval from its scheduled administration time (this interval should be established by each individual healthcare facility).
Unauthorized drug error
Dispensing or administration to the patient of medication not authorized by a legitimate prescribe r.
Dose error
Dispensing or administration to the patient of a dose that is greater than or less than the amount ordered by the prescribe r or administration of multiple doses to the patient, i.e.   one or more dosage units in addition to those that were ordered.
Dosage form error
Dispensing or administration to the patient of a drug product in a different dosage form than that ordered by the prescribe r.
 Drug preparation error
 Drug  product  incorrectly  formulated  or  manipulated  before  dispensing  or administration.
Route of administration error
Wrong route of administration of the correct drug.
Administration technique error
Inappropriate procedure or improper technique in the administration of a drug other than wrong route.
Deteriorated drug error
Dispensing or administration of a drug that has expired or for which the physical or chemical dosage-form integrity has been compromised
Monitoring error
Failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy.Medication Errors Case Study Paper
Compliance error
Inappropriate patient behavior regarding adherence to a prescribed medication regimen.
Other medication error
Any medication error that does not fall into one of the above predefined types

Causes of Medication Errors

Distraction : A nurse who is distracted may read “diazepam” as “diltiazem.” The outcome is not insignificant-if diazepam is accidentally administered, it could sedate the patient, or worse (e.g., if the patient has an allergy to the drug).
Environment : A nurse who is chronically overworked can make medication errors out of exhaustion. Additionally, lack of proper lighting, heat/cold, and other environmental factors can cause distractions that lead to errors.
Lack of knowledge/understanding : Nurses who lack complete knowledge about how a drug works, its various names (generic and brand), its side effects, its contraindications, etc. can make errors.
Incomplete patient information : Lacking information about which medications a patient is allergic to, other medications the patient is taking, previous diagnoses, or current lab results can all lead to errors. Nurses who aren’t sure should always ask the physician or cross-check with another nurse.Medication Errors Case Study Paper
Memory lapses : A nurse may know that a patient is allergic, but forget. This is often caused by distractions. Forgetting to specify a maximum daily dose for an “as required” drug is another example of a memory-based error.
Systemic problems : Medications that aren’t properly labeled, medications with similar names placed in close proximity to one another, lack of bar code scanning system, and other issues can lead to medical errors.

Preventing Medication Errors

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:

Know the Patient

This includes the patient’s name, age, date of birth, weight, vital signs, allergies, diagnosis, and current lab results. If patients have a barcode armband-use it. The added administration times of using arm band systems have led some nurses to create potentially dangerous “workarounds” to avoid scanning barcodes. Don’t make this potentially dangerous mistake- use all of the information at your disposal to ensure patient safety, and avoid shortcuts.Medication Errors Case Study Paper

Know the Drug

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. If you have any questions or concerns about a drug, don’t ignore your instincts-ask. Remember that you are still culpable, even if the physician prescribed the wrong medication, the wrong dose, the wrong frequency, etc.

Keep Lines of Communication Open

Breakdowns in communication among physicians, nurses, pharmacists, and others in the healthcare system can lead to medication errors. The “SBAR” method can help alleviate miscommunications. SBAR (Situation, Background, Assessment, Recommendation) works like this:

Situation : “The situation is that Mr. Smith is complaining of chest pain.”
Background : “He had hip surgery yesterday. About two hours ago he began complaining of chest discomfort. His pulse is 115, and he is short of breath and agitated.”
Assessment : “My assessment is that Mr. Smith may be having a cardiac event.”
Recommendation : “My recommendation is that you see him immediately, and that we start him on O2 and administer an analgesic immediately. Do you agree?”Medication Errors Case Study Paper

Communication is vitally important, as it is the root cause of many sentinel events, according to the Joint Commission (TJC).5

Double Check High Alert Medicines

High-alert medicines such as heparin can have devastating consequences if not administered properly. A tragic case involving the death of three infant patients after receiving massive heparin overdoses happened as a result of misleading packaging. 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. Double check high alert medications with another nurse to prevent accidental overdoses and other medication errors.

Document Each Drug Administered

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.

Take an Active Role in Correcting Issues You Identify

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. Request that medications be reconciled (i.e., that the names, dosages, and administration routes of all medications are compared to identify conflicts). 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).

Strategies for Preventing Medication Errors

It is important for all nurses to become familiar with various strategies to prevent or reduce the likelihood of medication errors. Here are ten strategies to help you do just that.Medication Errors Case Study Paper

1. Ensure the five rights of medication administration.

Nurses must ensure that institutional policies related to medication transcription are followed. It isn’t adequate to transcribe the medication as prescribed, but to ensure the correct medication is prescribed for the correct patient, in the correct dosage, via the correct route, and timed correctly (also known as the five rights).

2. Follow proper medication reconciliation procedures.

Institutions must have mechanisms in place for medication reconciliation when transferring a patient from one institution to the next or from one unit to the next in the same institution. Review and verify each medication for the correct patient, correct medication, correct dosage, correct route, and correct time against the transfer orders, or medications listed on the transfer documents. Nurses must compare this to the medication administration record (MAR). Often not all elements of a medication record are available for easy verification, but it is of paramount importance to verify with every possible source—including the discharging or transferring institution/unit, the patient or patient’s family, and physician—to prevent potential errors related to improper reconciliation. There are several forms for medication reconciliation available from various vendors.Medication Errors Case Study Paper

3. Double check—or even triple check—procedures.

This is a process whereby another nurse on the same shift or an incoming shift reviews all new orders to ensure each patient’s order is noted and transcribed correctly on the physician’s order and the medication administration record (MAR) or the treatment administration record. Some institutions have a chart flag process in place to highlight charts with new orders that require order verification.

4. Have the physician (or another nurse) read it back.

This is a process whereby a nurse reads back an order to the prescribing physician to ensure the ordered medication is transcribed correctly. This process can also be carried out from one nurse to the next whereby a nurse reads back an order transcribed to the physician’s order form to another nurse as the MAR is reviewed to ensure accuracy.

5. Consider using a name alert.

Some institutions use name alerts to prevent similar sounding patient names from potential medication mix up. Names such as Johnson and Johnston can lead to easy confusion on the part of nursing staff, so it is for this reason that name alerts posted in front of the MAR can prevent medication errors.

6. Place a zero in front of the decimal point.

A dosage of 0.25mg can easily be construed as 25mg without the zero in front of the decimal point, and this can result in an adverse outcome for a patient.

7. Document everything.

This includes proper medication labeling, legible documentation, or proper recording of administered medication. A lack of proper documentation for any medication can result in an error. For example, a nurse forgetting to document an as needed medication can result in another dosage being administered by another nurse since no documentation denoting previous administration exists. Reading the prescription label and expiration date of the medication is also another best practice. A correct medication can have an incorrect label or vice versa, and this can also lead to a med error.Medication Errors Case Study Paper

8. Ensure proper storage of medications for proper efficacy.

Medications that should be refrigerated must be kept refrigerated to maintain efficacy, and similarly, medications that should be kept at room temperature should be stored accordingly. Most biological s require refrigeration, and if a multi dose vial is used, it must be labeled to ensure it is not used beyond its expiration date from the date it was opened.

9. Learn your institution’s medication administration policies, regulations, and guidelines.

In order for nurses to follow an institution’s medication policy, they must become familiar with the content of the policy. This is where education comes into play whereby the institution’s educator or education department educates nurses on the content of their medication policy. These policies often contain vital information regarding the institution’s practices on medication ordering, transcription, administration, and documentation. Nurses can also familiarize themselves with guidelines such as the Beers’ list, black box warning labels, and look alike/sound alike medication lists.

10. Consider having a drug guide available at all times.

Whether it’s print or electronic is a matter of personal (or institutional) preference, but both are equally valuable in providing important information on most categories of medication, including: trade and generic names, therapeutic class, drug-to-drug interactions, dosing, nursing considerations, side effects/adverse reactions, and drug cautionary such as “do not crush, or give with meals.”Medication Errors Case Study Paper

Utilizing any or all of the above strategies can help to prevent or reduce medication errors. Nurses must never cease to remember that a medication error can lead to a fatal outcome and it is for this reason that med safety matters.

Safety during patient hospitalization consists one of their rights and also the first priority of health professionals. Errors that occur during the application of medical/nursing interventions or patient hospitalization have drawn health researchers’ attention over the last decade. Errors appearing in the hospital settings concern a lot of incidents like patients falls, use of wrong equipment, sores, hospitals infections, improper management of clinical situations and medication errors. Medication error defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer” [1].

It is estimated that medication errors in USA account 7000 deaths annually. However, this estimation represents the number of medication errors that resulted in death. Actually, the possibilities of medication errors to result to death is 0,1% [2]. Mostly medication errors are identified before they reach the patient, or they reach the patient but do not cause harm, or cause permanent harm and required prolonged hospitalization. Moreover, there are medication errors that require necessary interventions to sustain life [3]. Medication Errors Case Study Paper

Studies that examined the types of medication errors divided them in categories, according to the description of the event: omission error, wrong drug error, wrong patient error, wrong route error, wrong time error, wrong technique error, wrong dosage-form error and extra dose error [4]. Thus, to avoid any type of medication error made by nurse, the implementation of preventive measures is undoubtedly beneficial. Nurses taking into account all precautions for medication errors, reduce firstly the incidence of medication errors, maintain the culture of safe hospital environment and ensure safe medications management by them.

A breakdown of the relevant literature showed that the protective measures for medication errors are related with the preparation and the administration of medications, the dosing calculations skills, the nursing education, the oral medication orders, the interdisciplinary collaboration, the administrative nursing staff and other measures.

Medication preparation and administration

Medication safety aims at the reduction of medications errors rates, their earlier identification before patient gets harm and their timely treatment [5]. Preventive strategies of medication errors include the standardization and the simplification of medication procedures and others. Medication preparation and administration are parts of medication procedures, which involve the follow measures:

• the insurance of a safe environment for the medication preparation by placing labels (“Do not disturb”, to discourage visitors to interrupt the nurse that time) and also to remind nurses the importance of concentration during medication preparation, [6,7].

• the reduction of distractions and interruptions during medication administration,

• the assistive use of calculator to facilitate the resolution of the calculations [8]. Using a calculator, however, requires knowledge of the existing data management, the way data will be used and the conversions that are required [9]. Thus, the use of calculator will serve as a “useful tool” for resolving the various mathematical functions and conversions [10].

• the delivery of premixed medications from pharmacy to nursing wards without needed any further dialysis or special preparation by the nursing staff (especially pediatrics medications that require precision in dosage calculation) [11].


• the mandatory double-checking of medication by two separate nurses (particularly in high risk medications, which are usually responsible for adverse events or errors),

• the implementation of “five rights” (right medication, right dose, right route, right time, right patient) when preparing medications (although this factor focuses on individual performance and does not reflect the complexity of medication procedure) [12].

• the apparent separation of medications with similarities either in color or in name, by putting a label on them [13].

• the preparation and the administration of medication the same time [14].

• and the check if medication had been administrated to the proper patient [15].

Dosing calculation skills and nursing education

Another protective measure against medication errors consider to be the improvement of dosing calculation skills through nursing education. This can make nursing students prepared for their clinical duties afterwards. Directly related to the above, are the mathematical competencies of the nursing students.16 Skills involving fractions, decimals and percents, are examples that complicate the application of mathematic operations, as Brown mentioned [17].Medication Errors Case Study Paper

The article entitled: “Clinical skills: a practical guide to working out drug calculations” written by Trim, [18] analyzed thoroughly all types of medication calculations. Emanuel and Prynce-Miller, considered the establishment of protocols in clinical practice, as a duty. So, it would be easier for nursing students to meet correctly dosing calculations [19].

Both students and professional nurses, believe that what they knew was sufficient to calculate doses (tablets, injections), the way of medication administration, medication terms and medication abbreviations was known almost from both groups. Subjects in which knowledge was lessen were pharmacodynamics and pharmacokinetics, [20] dosing calculation of liquid solutions and dilutions.16 In a study, to assess unsafe events for patients, found that 56% of unsafe events related to medication errors and 20% of those associated with lack of nursing student skills [21].

Attendance of educational courses that improve dosing calculation skills through mathematical tests seems useful. Particularly, the provision of books with exercises examples and recommendations of some books to study are enhancing students’ skills of learning [22]. Strengthening nursing students’ theoretical pharmacological background will help them to recognize medication errors, as they will become future nurses. Alongside the theoretical background is the clinical practice. At this point enters the role of clinical nurses’ educators to teach all required skills to their students to avoid any type of error in the future [23-25].Medication Errors Case Study Paper

Oral medication orders and interdisciplinary collaboration

Oral medication orders transmitted by phone from a doctor to a nurse are hiding risks. The existence of voices or noises in the environment of the speakers, the unfamiliarity with patients’ situation, bad phone connection and rapid way of speaking, are some factors that make communication through phone difficult [26]. So as to avoid errors in these cases, it is important firstly to write down the order, then confirm patients’ name, medications’ name, the precise dosing and the reason of administrate this medication to the patient. All these actions, is proposed to take place before the doctor hang up the telephone [27,28].

Particularly valuable is the cooperation of doctors, nurses and pharmacists for establishing policies, strategies and systems that will reduce the incidence of medication errors [12]. Interdisciplinary cooperation needs to obtain a comprehensive view about the issue of medication errors, their causes and the way every health care professional faces medication errors [29].

Measures concerning nursing administrators

There is growing evidence that nursing administrators possess central role in the management of medication errors [30]. The head nurses have strong influence in clinical nurses’ conduct to keep positive attitude towards the reporting of medication errors [30,31]. The cooperation of head nurses and nurses aims to the understood of each group beliefs of creating a safe environment of health care [32].

The head nurses decision to minimize phone calls during drug administration time (8:30-10:00 am, 8:30 to 10:00 pm) is necessary [7]. In the duties of nursing administrators include also the creation of a safety culture of hospitalized patients, the motivation of managers to be constantly vigilant and to promote conditions that enable the treatment of medication errors by the nursing staff of each clinic [29]. Medication Errors Case Study Paper

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