Medication Safety

I have been touched by the many recent news headlines of medication errors, especially those involving newborns. In yesterday’s news covering a Las Vegas malpractice case, a sobbing pharmacist was apologizing to the parents of a deceased infant who was the recipient of a drug overdose prepared during her watch. The pharmacist was so distraught that the mother of the deceased infant left her seat in the court room to comfort her. Our text discusses the potentially harmful effects of medications during pregnancy, during Iabor, and to newborns. In watching the coverage and reading the text, I was reminded of the many times during my career that I have witnessed errors and myself experienced serious near misses with medication administration. It is devastating when such events occur to both the patient and the health care practitioner. Safe administration of medications has always been the goal of healthcare providers, but it seems that despite all of the resources available, errors continue at alarming rates. This is so much the case that The Joint Commission has charged hospitals to improve the safety of medication administration in their National Patient Safety Goals. Information regarding dosing, drug interactions, etc. is readily available in many formats to those preparing and administering medications. We have medications provided in unit dose increments and dispensed by machines. As a standard of nursing care, we perform a minimum of five checks before administering medications. Some medications require two nurses to verify the dose. We have changed our practices with patient identification to reduce the likelihood that medication is given to the wrong person. Yet, with all of the available information and redundancies built into the system, life threatening errors occur. There is a federal movement underfoot for all healthcare organizations to have electronic medical records in place. A medication administration record that does not require manual transcription would be an adjunct in reducing transcription errors. However, the data base is only as good as the information that it is provided with, leaving the potential entry for errors. Electronic data bases provide very useful information for tracking, measuring and determining clinical quality. This would help us evaluate process errors and to revises processes based on the knowledge gained. At the end of the day, with all the tools and information at hand, it is the end user who is the last and most important stopgap in safe medication administration. The available tools are like a hammer. A great hammer still needs a skilled carpenter to achieve a great outcome. It is my belief that our focus should be in development of the “carpenter” and the processes used by the “carpenter” with regard to medications. This would involve more training with medications; time to recalculate what is prepared in pharmacies, and an evaluation of the environment, including patient assignments and ratios. The costs incurred would be minimal compared to the cost of a human life or a lawsuit related to negligent practice.

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