Medication Errors


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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