Forensic Nursing Chronicles

Not only do medication errors affect patients they also affect nurses, doctors, and the hospital in which it happened. It is not only in our best interest, but in the interest of the patient to figure out to avoid and fix the problems that currently lead to medication errors. It has been noted that three main reasons for medication errors include human errors, system failures, and communication failures. Communication failures being the number one reason for medication errors. We can prevent errors by improving the systems that guide health care practice.
Communication errors occur most often because we talk a lot! We can be rushing around at work and a physician comes in and gives a verbal order. For me I need to write it down immediately and then I repeat it back to them to make sure I heard them correctly. Other times, if I am busy or in the middle of something I tell the physician that I will do it as soon as they write it as an order. By asking them to write it down not only makes them accountable for the order, but if I have a question about it I can run it by another nurse for clarification. There also seems to be an increase in foreign doctors, especially where I work. If I am taking a verbal order, I always repeat what they have said to me back to them and ask if that is correct. We also have to sign our orders stating “read back and confirmed”. What they said very often is not what I heard. In the end if I write an incorrect order it falls back on me because I am the one who wrote it. I am very anal when it comes to orders and have many times annoyed physicians by asking them to repeat what they said or to have them spell it for me. As long as I have the patient’s best interest in my mind, I don’t care that they are annoyed with me! I am not there to appease them, I am there working for the best interest of my patient.
Systems failures include poorly developed prescription, transcription, delivery, and administration, protocols and a lack of checks and balances. Automatic checks and balances help decrease human failures and alert clinicians to errors so they can be corrected before they reach the patient. My hospital is working on implementing a new medication delivery system that includes an improved method of checks and balances. In the future will have to have all orders go through pharmacy via computer and will not be allowed to receive any meds until all checks have been done correctly. Currently, if a new order is written the charge nurse takes it off and puts it on the patient’s MAR. After doing this it is up to the nurse caring for that patient to make sure they get the correct med. By implementing the new computer system, all orders will have to go through pharmacy, via computer, in order for them to be taken off the chart. The perfect example of this is an error that occurred last year. A coworker of mine had an order to transfuse her patient with a unit of PRBC’s. Before administering the blood the patient was to receive Tylenol and Benadryl. The orders were handwritten on the MAR by the charge nurse and my coworker was informed of the order. We stock Tylenol and Benadryl on our carts so the nurse went ahead and gave them to the patient, instead of waiting for them to arrive from pharmacy. After the meds had been given, pharmacy got the order and called the floor and asked why the physician had ordered Benadryl for the patient because she was allergic to it. In this case, who is to blame? The physician who ordered the med, the charge nurse who took the order off, or the nurse who gave the med? Everyone wanted to blame the next person in line and no one wanted to step up and say they were wrong for not checking the client’s allergies. The patient ended up making it through okay and my coworker got written up for it. Chalk it to another lesson learned by all involved.
After reading several articles on the subject a common theme seemed to be that younger nurses, who have been in the field less than five years, said that human errors were the most important source of errors. To me this means that we all need more education on the matter. One way to educate is to share with others the mistakes you have made, and how they affected you and how you learned from them. I tell my students about the med error I made the first year I was on my own. It makes them see me as human and lets them know that everyone can, and usually will at least once in their career, make a medication error. It is what we do after the error that will guide our future care.
There are many other reasons medication errors occur. Understaffing, penmanship of those writing orders, verbal orders, and use of abbreviations are just a few. When a facility realizes they have a problem it is what they do to try to fix it that really matters most. Not only is my hospital going to an all computerized medication delivery system soon, but we have other checks in place. Administration has an approved list of abbreviations for us to use. If physicians use one that is not approved the order does not get filled until they come and clarify it. We are also, in the near future, going to establish a system that is all electronic. The MAR’s, medications themselves and patient name bracelet’s will all have to be scanned, all prior to being administered. These are all attempts to further reduce the amount of medication errors that actually happen and are reported. I believe that my hospital is on the right track to the future and reducing medication errors.

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forensic nursing chronicles
forensic nursing
forensic nursing theories
forensic nursing diagnosis
medication errors