Medication errors are a major cause of morbidity and mortality. They can be made by any member of the
healthcare team, physicians, pharmacists, or nurses. Common causes of errors include performance deficits
and knowledge deficits. Cooperative relations between all members of the healthcare team is paramount to
develop protocols for patient safety.

An example of a performance deficit would be a drug given via a wrong route. A few years ago there was a graduate nurse on the medical-surgical floor I work on, the nurse spoke with the patient’s doctor who gave him an order for vistaril over the phone. He wrote the order as he believed the doctor ordered it. He drew the correct dose into a syringe and proceeded to give the medication intravenously. The patient cried out in pain almost instantly, due to inexperience he did not realize that this drug is caustic to veins and should only be given PO or IM as was suppose to be the correct route here. Implementations have now been put in place with the cooperation of the pharmacy staff to help prevent this to occur again, we now have triggers and markers near the drug bins in plain site, and at times attached to drug vials stating any safety issue for the medication, this has been very effective and we have not had a similar incident.

An example of a knowledge deficit that would cause a medication error would be a drug given at an inappropriate time or manner, such as a medication being inappropriately crushed. In cooperation with pharmacy staff many medications have specific times for administering such as coumadin, given daily usually means 9 AM, however since coumadin should not be taken with any foods rich in vitamin K it has a specific time away from meals that it is given each day. Other medications need to be given on an empty stomach so that food does not decrease their absorption, while others need to be taken with food to avoid gastrointestinal upset or increase their absorption as with certain HIV drugs. Enteric coated medications are designed to be absorbed in the intestine, bypassing the stomach, in order to protect the stomach from a drug that may cause gastric upset, or to protect the medication from the acid and pepsin in the stomach. It is an error if these are given inappropriately by crushing them, medication safety education and promoting the use of physicians and pharmacists to overcome these obstacles is our challenge, physicians can order and pharmacists can recommend a different form of the drug such as a liquid rather than pill or capsule to meet the unique needs of these patients. Knowledge of pharmacokinetic factors can aid in maximizing the effects and minimizing harm by selection of appropriate route, dose and dosing schedule.

Prevention is an institutional wide process. Identifying errors in a nonpunative environment focusing on a process to prevent errors, rather than naming and blaming, encourages identification of errors and the development of new patient safety systems. The nurse is the patients last line of defense against medication errors made by others, and also the last person with opportunity to introduce an error.

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