Archive for July, 2007

Medication Errors

July 31, 2007

In the battle against medication errors, the patients are still losing. Many programs have been implemented to reduce the unintentional errors that nurses make in response to giving out medications. Our hospital has many safety programs put into place. We have no high risk medications on open floors. Narcotics are locked up and are in single dose form. When the nurse is going to give a medication, she first scans the patient bracelet, then scans the medication. You would think this would be fool proof. But in fact errors still happen. Nurses at times in a hurry and not wanting to take the time to take the computer into the patients room will scan a bar code from the chart. The nurse could be scanning the right bar code, but by only scanning the bar code and not the actual bracelet on the patient, she could be at the wrong patient room. Another safety feature that has its flaws is that when a medication is scanned it will alert you if it is the wrong medication or the wrong time. The problem is that it alerts the nurses so much they may tend to ignore the warning. For example, if your patient has morphine 2 mg ordered, and the accudose is out of the 2 mg syringes, you may take a 10 mg syringe, waste 8 mg, and plan to give the 2 mg. This is correct but since you are trying to scan the 10 mg syringe, the computer will tell you that you are making an error. The problem can be fixed, but it takes time and paperwork. It always involves filling out a pharmacy variance report. What nurse with 6 or more patients has time to do this? I think the answer is a lower nurse patient ratio, not more programs and safety features.

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Response to the listing “Medical Errors”

July 26, 2007

This is in response to the listing “Medical Errors”

I would like to respond to this response from the Quality Director. She was talking about how she is responsible for investigating all medication errors in her facility and finding a solution. I was at a conference for Nurse Educators this past week. One of the statements made was how medication errors by nurses are responsible for a large majority of lawsuits.

I took this information back to my students and we talked about how this can happen. We discussed that in order to administer medications, a nurse must have a current license and a medication order signed by a practitioner licensed with prescription privileges. We discussed that the nurse must understand the client’s diagnosis and symptoms as they pertain to the medications they are getting. It is the nurse’s responsibility to know why a medication is ordered, actions, dosing, route, side effects, adverse reactions, contraindications, and drug compatibility. The nurse must also take an active role in the education of the client and family. This information the nurse needs to safely administer medications follows the nursing process. Assessment is an ongoing process. Nursing diagnosis helps to identify problems. Planning helps one to be ready to recognize therapeutic, side effects, and adverse reactions. Nursing interventions allow the nurse to perform baseline assessments and additional assessments to establish goals. Evaluation is an ongoing process as well. The nurse must assess, collect data and evaluate her client on an ongoing basis to be certain that the therapeutic effects and adverse effects of a medication regime are noted. I pointed out to my students that being “unfamiliar” with a medication is considered negligence.

We teach students the proper way to identify a client. They must have two patient identifiers. Examples of these would be validation of patient name, medical record number, or date of birth. These can be found on the arm band and patient worksheet. They are responsible for asking drug allergies at the bedside prior to medication administration. We teach them to do three checks on their medication. The three checks include; first to check the original doctor’s order with their worksheet, second to check their medication against the worksheet when pulling it from the pyxis machine, and third at the bedside in front of the patient. We also teach the five rights of medication administration: right drug, right dose, right route, right time, and right patient. One of the ways our hospital facility has tried to decrease medication errors is to have a mat placed on the floor in front of the pyxis machine that says “quiet zone”. When someone is on the mat, no one is to talk to them. There are also signs posted in the medication room warning of SALAD; sound alike, look alike drugs. Our facility has identified a list
of “unsafe” abbreviations. The doctors may no longer use certain abbreviations when writing orders. A few examples related to medications are: must write out units not U, magnesium sulfate not MgSO4, morphine sulfate not MSO4, and daily instead Q.D.

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Carisoprodol, meprobamate, and driving impairment

July 25, 2007

Logan, B K. Case, G A. and Gordon, A M. wrote a paper in the Journal of Forensic Sciences in May 2000. It suggested that driving was impaired when using carisoprodol and its metabolite meprobamate. Literature implicating these drugs in impaired driving was reviewed. A series of 104 incidents in which these drugs were detected in the blood of drivers involved in accidents or arrested for impaired driving was considered, with respect to the analytical behaviors exhibited, and the symptoms observed in the drivers. Reporting driving behaviors included erratic lane travel, weaving, driving slowly, swerving, stopping in traffic, and hitting parked cars. Driver on contact with police had poor balance, slurred speech, unsteadiness, slow responses and difficulty standing. Many of these cases had alcohol and other centrally acting drugs present also making it difficult to attribute impairment specifically to carisoprodol and meprobamate. In 21 cases however, no other drugs were detected and similar symptoms were present. Impairment appeared to be possible at any concentration of these two drugs and the most overt symptoms of intoxication were noted when the combined concentration exceeded 10 mg/L, a level still within the normal therapeutic range.

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Fatal overdose with citalopram

July 24, 2007

The Department of Forensic Medicine at Umea University in Sweden reported on six forensically investigated suicides where overdose with the SSRI citalopram was found. In all cases, a strong evidence of acute overdose was found, and the forensic investigation did not reveal other causes or modes of death. The post-mortem concentrations of citalpram in the blood were between 5.2-49 micrograms. For comparison, in 335 other post-mortem blood analysis performed among non-overdose deaths, post mortem citalopram concentrations varied between 0.06 and 7.0 micrograms. The therapeutic concentration in post-mortem blood has been reported to be 0.3 micrograms, which is well below the concentrations in their cases. One possible mechanism of death is cardiac arrhythmias. Citalopram prolongs the QT interval. In a recent report to the Swedish Medical Products Agency the QT interval increased to 0.504 is a woman after overdose with citalopram. Seizures represent another mechanism of death, which cannot be completely ruled out. Until further study of citalopram toxicity is done the team in Sweden recommended the same precautions in prescription of citalopram as with tricyclic antidepressants to patients with a high risk of suicide.

The Lancet August 1996

Ostam, Mats; Eriksson, Anders; Thorson, Jan; Spigset, Olav

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Female Genital Mutilation

July 19, 2007

I was truly amazed to read about FGM. I did not realize this went on in other countries, as well as our country. I have been a nurse for 15 years and have never taken care of a female patient that had been through FGM, nor did we learn about it in nursing school. As a forensic nurse, you do have to be aware of these situations and that some cultures do continue to practice FGM. The nurse would be responsible for assessing the woman for any kind of complications the woman may suffer after having this done, whether it be during childbirth, ongoing infections, or dysmenorrhea. I’m glad I had the opportunity to learn about FGM and all the risks associated with it, and that the nurse must be culturally sensitive in these cases.

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Comment: Female Genital Mutilation/Female Circumcision posted Sunday, March 11, 2007

July 18, 2007

I read the posting by one of the students in the Forensic Nursing class about Female Genital Mutilation/ Female Circumcision. I did do a little research since reading your comments. I may not agree with this practice and can’t even begin to understand the cultures that continue this. I believe that it would be hard to educate a woman about this if she truly believes that it is proper based on her cultural belief. I am a Labor & Delivery nurse and had done minimal research on this practice. I have had the experience of taking care of a woman who had undergone this procedure. This particular patient had a typical first stage of labor; however the circumcision complicated the delivery. The physician had to cut a rather extensive episiotomy to facilitate the delivery of the baby. The repair after delivery was rather complicated for the physician as well. Trying to figure out what went where was a challenge. My role as the nurse was on patient education after delivery for this young mother. My assessment skills needed to be sharp and I needed to be extra careful with her. I needed to be assessing for hemorrhaging, infection, and urinary complications. I needed to stress to her the importance of proper hygiene so that the perineum would heal and be free of infection. As much as I would have loved to have had the conversation about the circumcision procedure itself, I needed to remain culturally sensitive to her background.









An Original, Standardized, Emergency Department Sexual Assault Medication Order Sheet

July 17, 2007

I read this article in the Journal of Emergency Nursing. An interdisciplinary group at the Massachusetts General Hospital emergency department created a standardized sexual assault medication order sheet. It follows sexually transmitted disease (STD) and HIV non-occupational exposure recommendations from the Centers for Disease Control and Prevention (CDC) and the Massachusetts Department of Public Health (MDPH). It also includes alternative medications in the case of allergies to the first-line medications and features commentary for clinicians. The team believed that providing excellent standardized care to sexual assault patients was essential and improved the care while decreasing liability for nurses and physicians. Components of the medication order sheet included gonococcal infection, chlamydial infection, trichomoniasis, hepatitis B, pregnancy, tetanus, and HIV medication guidelines. It has been used for 1 year at the time of print of this article. It has received positive feedback that it is easy to use and eliminates confusion in choosing medications. In light of national data that demonstrate that sexual assault victims are not receiving adequate protections from infection and pregnancy it may be worthwhile for other institutions to adopt a similar approach to this national patient care problem.

Finkel: J Emerg Nurs, Volume 31(3).June2005.271-275









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