Medication Errors

Medication administration continues to be a high risk task for nurses. Errors can occur throughout the process – from the actual written order, pharmacy transcription, and nursing verification/review, to the administration of the medication. Breaks in the process are often caught and an error doesn’t reach the patient. In those cases where an error actually reaches the patient, most nurses feel badly about making the error and need support and a thorough analysis of the system and how it may have contributed to the error. I recently encountered a situation where a new nurse entered a patient weight in pounds instead of kilograms in a computerized program that had a field for kilograms only. In other words, the patient weighed 230 pounds and the nurse entered 230 kilograms. Doses of Vancomycin were given based on this weight. The patient developed acute renal failure before this error was caught. After doing a root cause analysis, several breaks in the process were identified and have been corrected. Our facility had recently changed the computer program to have a kilogram field only. Prior to this, the nurse would enter the number of pounds and the computer would convert that number to kilograms and populate the kilogram field. The other issue was the pharmacist not questioning the weight. This patient would have been over 500 pounds. After discussing the error with the nurse, I found her crying in the nurses’ lounge. As a manager, this incident reinforced my belief that nurses take their role very seriously and are deeply affected when a patient is harmed. Fixing the broken system was my focus and reassuring this nurse that identifying the error was not meant to punish but to identify where the system failed her. I am glad that most health care organizations have adopted a non-punitive approach to medical errors. By focusing on the process instead of the person, changes can occur that truly protect the patient from harm.

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