When medication errors occur the medical system traditionally looks for a person to blame so disciplinary action can occur. This might be an educational experience for the person involved or an experience in the court system if a malpractice suit is brought forth. The process of “finding someone to blame” starts with the institutions incident report process. An incident report is a necessary tracking and reporting tool but the focus of most formats is toward a person and does not takes processes into account.
Working in a management role and dealing with medication incident reports through the years I have come to the conclusion that most medical incidents are a multifactor event. Tracing the incident events back is much like following the “trail of bread crumbs” in the woods. In the majority of cases I have reviewed there is generally a series of small problems that lead to an error in the end. The individual at the point of care can be left with the blame when the “system” is prone to practice errors.
The original order given verbally or written can be the most interesting to study. Penmanship is an immense factor for the handwritten order. Abbreviations are a study onto themselves also with the current campaign to omit many of the favorites that are second nature to many of us in the medical profession. If the electronic medical record with the accompanying electronic signature is used you can eliminate some of the root causes of medication errors. The electronic system forces the user to select the drug with right spelling, dosage and route. Most of these systems can check for drug interactions at the click of a button further enhancing patient safety. Some systems cue the prescribers if they would like to order lab tests that are recommended for some medications. I feel the electronic medical record allow us to trace medication errors along the process. The order starts with a clear trail from the initial order prescribing to the administration of medications using this method. The electronic system will cue the person doing the entry of omissions or errors in most cases. I do not feel nursing staff should be the “someone to blame” when medical orders are not clearly written. It is inefficient for institutions to pay nursing staff for time spent clarifying poorly written orders.
tags
forensic nursing chronicles
forensic nursing
forensic nursing electronic medical record
Forensic Nursing Chronicles 