There is no simple answer to why medication errors occur. People die every year from preventable medical errors; wrong limbs are amputated, wrong organs removed, people receive the wrong medications, orders are incorrectly transcribed, medication reconciliation is often flawed, the list could go on forever. Errors are a result of human nature. While every effort is made to minimize and prevent errors, they still occur. Nursing education, annual and ongoing review of the Joint Commission National Patient Safety Goals, time outs prior to surgical procedures, are all great ways to work to prevent errors from occurring. Responses to errors should not be punitive; they are situations from which we learn. Errors result because processes fail.
Original Post
March 4, 2010
Title: “200,000 Americans Killed Each Year in Hospitals by Medical Error”
Listed in the above are common causes of medication errors: lack of sleep in caregivers, poor communication, illegible handwriting, poor staffing. These problems are encountered in all areas of patient care. There are never enough nurses, nurses have too many patients, work too many hours, and in reality are often rushed . Home medications are often not reported accurately and many physicians (who are also often rushed) write poorly. Several of the 2010 National Patient Safety Goals focus on medication administration as a result of reported medication errors. How do we change this? Change begins with education. Nurses must continue to learn about new medications and review old ones, never hesitating to consult resources if unsure about any aspect of a medication. As the last line of defense between the patient and a medication error, nurses must be dedicated to practicing the 5 Rights and the nursing process as it relates to medication administration, providing thorough assessments and evaluations even when rushed. Patients must be educated as well, and taught to ask and know about their medications, to report untoward effects and to learn about lifestyle changes which could reduce or eliminate the need for some medications. As nurses, we must continue to promote better nurse to patient ratio in all areas of care. We must exhibit professional and safe medication administration in our own practice and in mentoring new nurses just beginning their profession. The amount of reported medication errors is a sobering fact which should incite a call to all nurses and facilities to performance improvement in this area.
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