Medication Errors-A comment

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Medication errors continue to be a problem in healthcare causing undue harm to patients. My experience as a clinical leader on my unit is that the errors are a result of a poor system, frequent interruptions, and staffing issues. I am hopeful that the Physician order entry and eMAR…coming soon, are helpful in reducing our error rate and making the process more efficient. In review of errors we make, initial errors are a result of incorrectly profiled medications from Pharmacy. If not caught by the nurse, the error may reach the bedside. Others are in the delivery process where a Pyxis machine (a computerized medication station that links the patients profiled medication to a tower holding the medications) may direct the nurse to remove two to make the required dose and he or she may remove one. In review of the incident reports, it was determined that errors were linked to frequent interruptions during the delivery of medications. Nurses need to be able concentrate during this task but phone calls, pt requests, post-op patients arriving, needs of coworkers, chatter while in line at the Pyxis machine, family members needing attention all contribute to the fragment process. Our Pharmacy recently had to close at night due to a shortage of Pharmacists. The result from this was adding more towers and loading more drugs into the Pyxis machines and providing more override capability to nurses. Unfortunately at this time, space for Pyxis machines is limited so one of two machines is located in a hallway next to another open unit and in open view of patient rooms and hallway traffic. We are currently in the process of designing a booth-type barrier at the machine and implementing a system of rules during medication delivery. Wondering how the implementation of the computerized system will help. The interruptions and needs of patients will be the same. Human error in ordering and transcription will remain the same and the space issue on our unit will go unchanged.

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