Importance of implementation of safety when administering / using medications.

Improve Safety of Using Medication
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Improve Safety Of Using Medication
Patient Safety means freedom from unintentional injuries caused by medical care, abuse of services or lack of medical errors. Medical error is any avoidable event that can lead or cause an inappropriate use of medication or client injury while the control of the drug is under the supervision of a health care professional. Making errors are an essential part of any individual’s life. Most of the errors start from the behavioral and cognitive adaptations, which result in the development of the right behavioral skills. Carrying out medical orders are an essential part of the process of healing and caring for the patient. Also, an integral component of the nursing performance is the prominent role in the safety of the patient. Medication errors can affect the treatment cost and safety of the patient causing hazards for the sick person and their family. One of the critical duty of any nurse is giving medicine because of the resulting errors might have unintended, serious outcome for the patient. Medication errors can result in adverse consequences such as increased hospital duration of the patient, increased injuries or death cases, and increased expenses on medication. Despite the fact that most all health care members can cause a medical error, nurses commit most of the common medication errors. Since nurses are the one’s who execute most of the medical orders in hospitals and 40 percent of their time in the hospital is spent administering medicines.

The rates of Medication errors caused by nurses are high both in developing and developed countries.
Studies show that around 1.5 million people are injured yearly in American. In a report by the Institute of Medicine “To Err Is Human: Building a Safer Health System” indicated that medication errors were one of the leading causes of injuries and death. They claimed that “for one out of every 131 out patient’s deaths, and one out of 854 inpatient deaths” are caused by errors related to medication (Kohn, Corrigan & Donaldson, 1999). Also, the report shows that medication errors cause over 7,000 death yearly. Examples of medication errors committed by nurses include wrong dosage administration of a prescribed medication, a health provider failing to give a prescribed medication, a health care provider giving a wrong medication to the patient, right medication but given at the wrong time, or wrong combination of the drug. There are several causes of medical errors such as lack of experience or education concerning patient safety, incompetence, unreadable handwriting, staffing inadequacies, labeling of drug problems, excessive workloads, faulty dispensing systems, inaccurate documentation, language barriers, fatigue, and gross negligence (Altman, Clancy & Blendon, 2004). This causes challenge the way the nurses provide the right medication at the specified time for their patients. According to the “National Patient Safety Goals” article, it emphasizes the importance of improving the accuracy of the sick person’s identification. Improving communication effectiveness among caregivers, communicate and maintain correct medication information of the sick person. Making improvements concerning the safety of the clinical alarm systems and “prevent the safety of using medications” (“National Patient Safety Goals,” 2015), therefore, a necessity to improve the safety of using medication. The focus of writing this paper is to discuss the importance of improving the safety of using medication.
In 2006 a man who had diabetes and depended on insulin, collapsed and went into a coma while in the hospital. When the nurse discovered him, the man was not breathing and did not have a pulse. Also, his glucose level was nearly non-existent. Records obtained from the hospital revealed that the man had had a low blood glucose episode approximately three hours before. However, the nurses had disregarded the printed protocol by the hospital’s doctor for treating patients with hypoglycemia and also the written order by the patient’s physician to follow the protocol in case the man became hypoglycemic. The man was rushed to the intensive care unit whereby he died after three weeks.
A pediatric nurse decided to kill herself after she committed a harmful medical error. The nurse had made a mathematical error that resulted in the formation of a calcium chloride overdose, which subsequently led to the death of a child under her care. After investigations, the nurse agreed to pay for the damage. Also, she was terminated from her job that she had worked for several years, and was put on probation for four years. Unfortunately, she committed suicide two years later.
A nurse had been working her regular full-time shift during the day but agreed to stay later after her shift was over so that the hospital could have enough staff on the next shift. One of her new patients had been diagnosed with cancer and was supposed to be taken to the operation room to have a permanent intravenous line put in his chest. During the morning inspection round, the health care team in charge of the surgery decided to postpone the chemotherapy by one day. However, in the afternoon the doctor told the nurse that the chemotherapy would be done at night. The nurse already had four other patients to handle and did not expect any new thing to come up. Therefore, now the nurse would have another patient coming back from the operating room, and she was supposed to take the patient’s chemotherapy orders, send them to the pharmacy, and give him the treatment. After the nurse had checked the doctor’s orders, the patient had returned, and he was hungry. The nurse gave him some bread. Unfortunately, as the nurse was trying out his replaced IV line, she discovered it was leaking. Even the doctors had not noticed the problem it made the chief surgeon come back to the hospital and assess the situation. After everything was resolved the nurse gave the patient the scheduled chemotherapy and she went home exhausted. However, the following day the nurse received a call because a chemo drug was found in the drawer. The nurse realized that she had given the patient one drug and yet she was supposed to have given him two drugs. The nurse was shocked because the timing of medicines in chemotherapy can affect the treatment’s effectiveness. She was worried that her mistake would compromise the patient’s treatment and cause his death. She felt disappointed since her error had caused her to fail in her responsibility to ensure the patient’s safety. Fortunately, the mistake did not have any clinical consequences. The reason being the second drug could be taken within a specified period. Therefore, the nurse had few more hours remaining for the administration of the drug.
Most of the time people look at the impact the medication error has on the patient and fail to look at the damage it causes the nurse. Most of the time after a nurse makes a medication error she becomes traumatized and disappointed for making it instead of providing safety to the patient. The hospital may decide to suspend her or him. Sometimes they are sacked from their workplace. Nurses are usually filled with shame and guilt when they face the doctor in charge of their department after the mistake they did. Others nurses are taken to court and accused of the medication error. Sometimes they are requested to pay for damages. Sometimes, restrictions are put on their nursing license for a specified period by the disciplinary board (Anderson & Townsend, 2010). Therefore, the nurse cannot be hired to continue working as a nurse elsewhere. Some decide to commit suicide while others become hopeless in life.
Medical error issues have been present even during the time that Benjamin Franklin established the first America’s hospital whereby he stated that sick people eventually get hurt and die because of lacking proper nursing care. Also, research carried out show that nurses are the ones who account for most of the medical errors that occur in hospitals. According to a report written by Jill Gladstone after carrying out a study on medication errors and measures, found out that more than a half of all medication errors were as a result of dosage related issues, which were associated with intravenous medications.
According to the Institute of Medicine report in 2007, based on increased death numbers of patients because of medication errors, emphasized on an integral part of the health care system was decreasing the medical errors. It also stressed on ensuring better communication between patient and the caregiver, encouraged the continuation of error monitoring, giving clinicians’ decision support tools. Also, “standardizing and improving drug related and medication labeling ‘(Aspden, Wolcott, Bootman, & Cronenwelt, 2007). Another study was done by the American Nurses Association in 2007, about medication errors because of injectable, found out that the errors could be reduced if the syringes were labeled. The research was designed to capture the recommends of the Joint Commission goals. The study found out that more than 28 percent of the nurses do not label syringes while using them. The research team recommended that there was a need for healthcare systems to improve the employees and patients safety by addressing the challenges connected to medication errors caused by the injectable. Based on the researchers desire to conform to the Joint Commission aim for labeling medications, they recommend the adding of a Stripe to allow critical data be written directly on the syringe barrel.
The Iran Journal of Nursing and Midwifery Research carried out a study on how to “evaluate the types and causes of nursing medication errors” (Cheragi, Manoocheri, Mohammadnejad & Ehsani, 2014). The research team found out that most of the medication errors were associated with dosage administration and injections. The researchers concluded that the main causes of the medication errors were due to lack of sufficient pharmacological knowledge and shortage of nurses compared to the number of patients the nurses were handling. Therefore, the team recommended that despite the fact that it was impossible to eradicate all errors caused by medication, it was the duty of the nursing administrators to do their best to reduce and prevent the occurrence of the errors by planning and supervision. Also, they recommended that the management should create an environment whereby the nurses and other health workers could feel free to report the medical errors occurring in the institution. The management would be able to use the recorded stories to help them find out what the causes of the medical error and find ways to prevent it from occurring again.
For the government to be able to manage the medication error problem, it should implement a mandatory reporting system for all health care institutions. It would help the institutions to do their best to reduce the medication errors. They could invest in infrastructure such as information technology and environment to allow health care providers participate in the safety improvement process. Also, the government could offer education scholarship for workers who want to continue or increase their knowledge on a particular area in their field of specialization. In addition, the government should put restrictions on institutions that are not improving on their medical error issues by revoking their licenses. Manufacturer to assist in managing the medication errors could describe the recommended dosage on each packaging box before supplying them to their consumers such as a hospital or drug store. They should ensure that all syringes have a stripe on them. It would help the nurses and other health care providers to add critical information when necessary. Manufacturers should also insert a code on the packaging of the drug for easy barcode identification and computerization of the drug. It will improve on errors caused by similar sounding names (Altman, Clancy, & Blendon, 2004).
Nursing administrators, on the other hand, should develop special procedures and have written rules on high alert drugs. For example, use of written guidelines, dose limits, double checks, special labeling, pre-printed orders checklists. They should also periodically educate the staff that is the physicians, pharmacists, nurses and other clinicians who are involved in the administration process of the medications from ordering, dispensing, monitoring and administering medication. Also, they should ensure that the drug information is up to date by updating new drugs information. In addition, they should make sure drugs that are not used frequently can be accessed by the clinicians quickly preceding to ordering, administration, and medication. They can achieve this by organizing with the pharmacists to show the nurses and doctors where the medicines are stored. If any storage changes are made on the drug all the health providers should be updated.
The professional organizations should be able to invest in more research on how to better patient’s safety and reduce accidents in the hospital. They should provide their members with information and resources on how to reduce medical errors in their institutions. They should create websites and forums where different health care workers can network with other employees outside their institutions and exchange ideas and learn new ways to minimize the medication errors. They can also help the different healthcare organizations to organize workshops or courses that could improve their staff’s professional knowledge. Nurses should not extend their shifts as they need to relax and be alert when attending to the patients. They should educate the patients while in the hospital when being discharged, and in outpatient care concerning their medication (Hughes, & Blegen, 2008). F or example, explain to the patients in detail the type of medicine they are going to take, reasons for taking medicine, and how to take and use the medicine safely. In addition, they should encourage the patients to ask questions concerning the drugs prescribed to them.
The information will impact my nursing care because I will be very careful when administering any medication to a patient. I will always take breaks when I feel tired and not extend my shifts to avoid fatigue and keep my professional goal of ensuring that I take care of my patient’s safety. Also, after learning about the profession organizations, I would make it my responsibility to join one of the groups and networks with others to increase my knowledge on different issues in the nursing profession.
References
Altman, D. E., Clancy, C., & Blendon, R. J. (2004). Improving patient safety—five years after the IOM report. N Engl J Med, 351(20), 2041-2043.
Anderson, P., & Townsend, T. (2010). Medication errors: Don’t let them happen to you. American Nurse Today, 5(3), 23-28.
Aspden, P., Wolcott, J. A., Bootman, L., & Cronenwelt, L. R. (2007). Institute of Medicine, Preventing Medication Errors, Quality Chasm Series.
Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2014). Types and causes of medication errors from nurse’s viewpoint. Iranian journal of nursing and midwifery research, 18(3).
Hughes, R. G., & Blegen, M. A. (2008). Medication administration safety.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (1999). To err is human. Building a Safer Health System, 2000.
National Patient Safety Goals. (2015). Retrieved November 29, 2016, from http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf