Haw, C., Stubbs, J. and Dickens, G. (2014). Barriers to the reporting of medication administration errors and near misses: an interview
Amends the Public Health Service Act to make medication error information privileged for Federal and State administrative and civil judicial proceedings if the information is voluntarily submitted by a health care provider to a program, approved by the Secretary of Health and Human Services, for the purpose of developing and disseminating recommendations and information regarding preventing such errors (Medication Error Prevention Act, 2000).
Nurses are most involved in medication administration, shortly before any adverse drug events may emerge. They also have the unique role of detecting and preventing errors that occurred in the stages of prescribing, transcribing, and dispensing. Since adverse drug events most often occur in the prescription, transcription, and/or administration stages, promoting patient safety should have multi-factorial approaches that involve more than direct-care nursing staff. Also, human factors are the primary underlying cause of medication errors. Therefore, professional education and clinical in-services with individual and system focuses on patient safety issues are essential (Tzeng, Yin & Schneider,
To create an environment where these errors are a rare occurrence, all healthcare professionals must dedicate themselves to implementing QSEN's six core competencies each and every day. These professionals must also speak up when they see room for improvement in their workplace. Regardless of the healthcare setting or demographic of patients, safe outcomes are the purpose of providing patient-centered care. Since nurses are the largest subgroup of healthcare professionals, their ability to make strides towards improved medication administration is undeniable. As the nursing code of ethics states, nurses have the duty to protect the health and safety of those in their care (Winland-Brown, Lachman, O'Connor Swanson, 2015). By taking extra caution to administer medications correctly, this honorable obligation will always be within
An ineffective communication can lead to errors in patient’s misdiagnosis and even medication on admission, during hospital stay, and after discharge, and whether these errors were potentially harmful. Medication use is potentially dangerous. Polypharmacy is increasing, and makes it harder to keep track of side effects and interactions and of potentially inappropriate drug combinations. “The risk of serious consequences, hospitalization, and death due to medication errors increases with patients’ age and number of medications (Scand J Prim Health Care, 2012)”. For example, the GP is supposed to monitor the patient's regular medication, but does not always do so. Lack of monitoring and keeping track of patients’ medication use is a main cause when a patient is given inappropriate drugs. When the nurse fails to communicate successfully with patients, it costs. It costs in unnecessary pain, in avoidable deaths, in poor health outcomes and in the prolongation of
Recognizing, acknowledging, and understanding medication safety is important when administering medications. Understanding which medications are high-risk ones, being familiar with the medications being given, remembering the five most important rights when administering medications, communicating clearly, developing checking habits, and reporting the medication errors will lead to safe outcomes for the residents. However, errors do occur from a lack of experience, rushing, distractions, fatigue, doing too many things at once, not double checking, poor communication, and lack of team work. It is not only the staff that commit errors, but also the work environment that contributes to the medication error. Two examples are poor reporting systems
issues to be able to prevent them from happening again and it helps to do a better job.
Health information technology were developed to transform healthcare services, the way they are provided and compensated. Electronic prescribing (e-prescribing) becomes an internal part of that transformation process, which can be confirmed from annual Surescripts’ National Progress Report.
Technological advances have improved patient safety and quality of care. E-prescribing is a technological development that can contribute to patient safety by reducing prescribing errors. The Food and Drug Administration receives about 300 medication errors a month. This number can be reduced if all health care settings are adopters of e-prescribing. Our solution to medication errors is here, it is just a matter of implementing it into our
In a report by the Institute of Medicine (2006), Titled, Preventing Medication Errors, “The committee concludes that there are at least 1.5 million preventable adverse drug events (ADE’s) that occur in the United States each year.” These numbers are astonishing given the number of adults that are taking prescription medications daily. Most of the errors occur during the prescribing and administering steps and during an average hospital stay, a patient can expect to have one medication error occur every day (Institute of Medicine, 2006).
Next, you have computerized physician order entry systems. Over the past decade, physicians would annotate in the patient’s chart to order blood draws, urine analysis or physical therapy. With the benefit of an computerized physician order entry system, physicians can enter these orders right into the computer, without worrying if the order was missed from the paper chart. This system as well, eliminate the medical errors caused by poor penmanship. Additionally, it creates a more efficient way to process orders in a timely manner, rather than staff waiting on physicians to clarify illegible orders. Past studies propose that medication errors can be lessened by as much as 55% when a computerized physician order entry system is utilized alone, and by 83% when combined with a clinical decision support system that makes cautions in light of what the doctor orders. Using a computerized physician order entry system, particularly when it is connected to a clinical decision support, can result in improved efficiency and effectiveness of care. A more recent study shows the number of appropriate medication orders increases with the involvement of dosing frequency or dosing levels using a computerized
One significant barrier is the potential detrimental impact on physician and staff workflow. Computer-based systems that allow clinicians to prescribe drugs electronically are designed to automatically warn of potential medication errors, but a new study reveals clinicians often override the alerts and rely instead on their own judgment. A study, at Dana-Farber Cancer Institute showed that most clinicians find the current medication alerts a task of annoyance rather than a valuable tool for patient safety. Although the e-prescribing alert with improve medication safety, we the society will not see its benefit until there is a system to help clinicians better manage medication safety alerts. This study shed a light on the real value of e-prescribing alerts in the eyes of our clinicians. The results of this study are quite frightening, but one must know that clinicians in general override more that 90 percent of the drug interactions alerts and 77 percent of the drug allergy alerts. This high override rate of all alerts suggest that most clinicians see the utility of electronic medication alerts as very insufficient. The clinicians would rather have a system that alerts on e-prescribing at the right time for the right patient. This means that clinicians would like the system to be improved and separate out patients who have used a
Define e-prescribing and what an EHR system will automatically check when an e-prescription is entered by a Physician. E-prescribing is the ability to write a prescription and electronically transmit it to a pharmacy. The EHR checks for drug allergies, drug interactions, and other potential conflicts by using information in the patient’s medical record including past medical history, allergies, and complete medication list.
According to estimates, at least 1.5 million preventable medication errors and adverse drug events occur each year in the United States. One-third of all medication errors occur during the administration phase of medication delivery (Durham, 2015). Medication safety is freedom from preventable harm with medication use; therefore, nurses must promote patient safety by understanding their contributions to the prevention of medication error (Choo, Hutchinson, & Bucknall, 2010). Additionally, a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional. Thus, to promote medication safety, nurses must understand their roles in proper medication management and identify challenges that associated with medication safety.
ADEs associated with medication discrepancies can prolong hospital stays and, in the post-discharge period, may lead to emergency room visits, hospital readmissions, and utilization of other health care resources. Preventable adverse drug events (PADE) are associated with 1 of 5 injuries or deaths and a result of poorly designed systems, which often lack independent redundancies. Preventable ADEs at transition points of care account for 46-56% of all medication errors. One strategy to reduce PADEs and ADEs is to reconcile the medication orders between the two transition points. The Institute for Healthcare Improvement (IHI) deﬁnes medication reconciliation as a formal process to compile a list of all the medications a patient is taking before admission, and comparing it with the doctor’s admission, transfer and discharge orders. In 2007, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) acknowledged that reconciliation errors compromise the safety of drug use and recommended hospitals to develop a system for obtaining patients’ complete pharmacotherapeutic records, to ensure they receive the necessary drugs for the new