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Running head: IDENTIFYING MEDICATION ERRORS NURS-FPX Identifying Medication Errors Capella University NURS-FPX Identifying Medication Errors Nursing is one of the most admirable careers in healthcare and nurses make up the majority of time with their patients. As nurses strive to achieve optimal care for each of their patients, medication errors are a healthcare issue that is prevalent in the healthcare field among nurses across the United States. Studies show that medication errors have been made by over 64% of nurses and approximately 31% of these nurses reported these errors (Gorgich, Barfroshan, Ghoreishi & Yaghoobi, 2016). Medication errors are a major problem in the field of nursing and are most often avoidable. The most common types of these errors are giving the wrong dosage or infusion rates and the most common reasons for errors are high nurse-patient ratios, using abbreviations instead of full names of medications, inexperience, lack of adequate training and education, distractions and lack of scanning as a secondary check (Gorgich, Barfroshan, Ghoreishi & Yaghoobi, 2016). Although these errors are unfortunately a common occurrence, with the proper use of evidence-based practices, policies and procedures they can be prevented. Medication errors are classified as a sentinel event and is currently ranked as the 8th highest cause of death in the United States. Thomas et al. (2017) states that approximately 1.5 million patients are affected by medication errors annually and the effects of these errors can result in illnesses, prolonged hospitalizations, paralysis, comorbidities, injury, additional medical expenses for both the patient and the healthcare organization and even death (Thomas et al., 2017).
Elements of a Quality Improvement Initiative A quality improvement initiative is an effective plan that can combat issues such as medication errors. In order to create a successful quality improvement initiative, a Tripe Aim approach aimed at patient safety is recommended (Lingsma, Bottle, Middleton, Kievit, Steyerberg & Marange-van de Mheen, 2018). In order to do this, a collaborate approach should be utilized including administrative staff, management and nursing staff and all team members should work together to develop an initiative based on the needs of the organization. A root cause analysis should be conducted to see what areas are being affected most and the rationale behind why these errors are occurring should be conducted. The organization will need to measure the effects of these errors as well such as the occurrences of 30 day readmission rates, increased hospitalizations, injuries, costs and mortality rates. The Department of Health and Human Services developed an action plan along with other federal agencies that studies these errors and recommended a plan based on evidence-based practices (FDA, 2017). It recommends that all healthcare organizations require medications to be scanned multiple times prior to medication administration; once at the Pyxis station, once scanning the patients ID band and once again scanning the medication prior to administration (FDA, 2017). The Department of Health and Human Services also recommends that abbreviations are not used and the sound alike, look alike medications sound an alert to inform nursing staff to check the medication before taking it out of the Pyxis (FDA, 2017). Nursing education regarding medication administration through various ways such as in-services, online education resources and team huddles should be conducted to empower nurses to make better decisions when administering medications. Communication should also be clear from physicians and nursing staff regarding medication orders as well to decrease any confusion. By providing education and creating stops such as these, hospitals and patients will save money as Medicare and Medicaid do not cover expenses due to medication errors and injuries will be decreased significantly (Lingsma, Bottle, Middleton, Kievit, Steyerberg & Marange-van de Mheen, 2018).
well as upper management. Patients and their families can incur serious injuries, trauma and financial burdens due to medication errors. Nurses play a key role in the prevention of medical errors and are ultimately responsible for these errors as they are the ones administering medications to patients. Nurses should always ensure that they are providing the right medication to the right patient, at the right time, in the right route and for the right reason. Nurses also are responsible for coordinating care and communicating with physicians and other care providers. Pharmacists play a role in labeling medications; they can help reduce medication errors by educating patients and medical staff regarding safe medication administration as well as labeling look-alike, sound-alike drugs as such. Physicians and mid-level care providers can educate patients and input their own orders to ensure miscommunication does not occur. Lastly, administrative professionals are affected greatly by these errors as many negative consequences affect the organization such as non-payment by insurance companies and negative reputation for the hospitals (Bari, Khan & Rathore, 2016). Conclusion Medication administration is necessary for patient care in the hospital setting. However, in recent years medication errors during inpatient stays have significantly increased causing issues such as comorbidities, injuries, illness, increased costs, prolonged stays and death. By implementing evidence-based practices such as promoting medication error reporting, providing education and training among healthcare staff, ensuring second-nurse checks are completed as well as medication scanning and checking the 5 rights of medication administration, nurses can significantly decrease these errors and increase patient safety. References Bari, A., Khan, R. A., & Rathore, A. W. (2016). Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan journal of medical sciences , 32 (3),
523–528. https://doi.org/10.12669/pjms.323. Gorgich, E. A., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint. Global journal of health science , 8 (8), 54448. https://doi.org/10.5539/gjhs.v8n8p Koyama, A.K. & Sheridan Maddox, C.S. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality and Safety, 29 (7), 595-603. Doi:10.1136/bmjqs-2019- Lingsma, H., Bottle, A., Middleton, S., Kievit, J., Steyerberg, E. & Marange-van de Mheen, P. (2018). Evaluation of hospital outcomes: the relation between length-of-stay, readmission, and mortality in a large international administrative database. BMC Health Services Research, 18 (116), 31-96. Thomas, L., Donohue-Porter, P. & Stein-Fishbein, J. (2017). Impact of interruptions, distractions and cognitive load on procedure failures and medication administration errors. Journal of Nursing Care Quality, 32 (4), 309-317. Doi: 10.1097/ncq.0000000000000256. U.S Food and Drug Administration [FDA] (2017). Strategies to Reduce Medication Errors: Working to Improve Medication Safety Retrieved from: https://www.fda.gov/drugs/drug- information-consumers/strategies-reduce-medication-errors-working-improve- medication-safety
