Posts Tagged ‘Medication Error’

Medication Identification

February 9, 2009
In this day and time patients have to be their own advocate. Many take whatever the doctor prescribes and doesn’t even ask questions. When they are admitted to the hospital they possibly have no idea of what they are taking or why they are taking it. I guess working in the medical field my eyes have opened up and I realize that doctors are not perfect. They are overworked with a high patient load. Sometimes patients walk into the office and are surprised that the doctor does not remember them or what medications they are on. I think this is probably the normal. I have seen doctors order the wrong medications, order medications the patient is allergic to, forget to order medications, etc. We don’t want to alarm our patients but we must make sure that they see the advantage of being their own advocate. There is nothing wrong with asking questions. If the doctor seems too busy or annoyed, find another doctor. It is also vital to use the nurse as a resource. The public relies on doctors and pharmacists to keep up with their medication list. For some reason if they get a prescription filled at a different pharmacy, they think magically their regular pharmacist will know and add it to their list. Or if they see a different doctor, they think that doctor would have called and made sure they have the correct information on hand. As nurses I also think we have a responsibility to be strong advocates for our patients. We need to look after them, ensure their medications are correct, and most importantly, educate the patients on the importance of looking out for theirselves.

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Narcotic Abuse

February 6, 2009
An increase in potential narcotics diversions were occurring within our Emergency Department after an influx of Agency nurses. What was happening; pain meds were being administered without corresponding orders and single dose vials were being used as multidose vials. We discovered that orders were not being written when crucial conversations took place between practitioner and nurse. Nurses were adminstering meds based on verbal orders, not thinking to follow-up with the physician or even hand the chart to the physician so they could write the order “real time”. I had worked in the ER for many years prior to my current position and there was always a sense of trust between nurse and physician. You helped each other out by doing for the other or even prompting when necessary. I find it rather interesting that there seems to be a new culture within the department that seperates physician and nurse; a form of alientation that fosters distrust. You hear things like: “That’s not my job” by nurses when discussing giving meds without orders, or “I didn’t know he did not write the order” or “I can’t give these meds even though I had a verbal order?” The other issue of using single dose vials as multi-dose vials come from not wanting to waste resources and work-arounds. I can understand the issues presented here. It happens when the physician orders 1mg of Morphine that comes in a 2mg vial. The nurse withdraws the 1mg, administers it, then saves the other 1mg for later, knowing it will be used at some point in time. Unfortunatly, all these actions may and do cause suspicion. Narcotics diversion was becoming such an issue that we ended up contacting an agent from the NYS Health Department, Bureau of Narcotics Enforcement. Imagine my surprise when this gentleman showed up for his in-service sporting a utility belt complete with handcuffs and a lovely government-issue 9mm handgun. Needless to say, his in-service caught the attention of many staff members, not just our ER staff. His presentation was very inciteful, replete with numbers about jail time and fines. Some of the “simple” penalties exceeded $5,000, loss of license, etc. Our numbers regarding narcotics diversion did diminish after his visit, but time will tell if the department goes full circle right back were it started.

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Medication Safety

September 23, 2008

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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Medication Error, comment

September 10, 2008

Medication error:
I too agree that many different things go wrong when there is a medication error made. I totally agree that patients need to take some responsibility for them. I recently had a patient who wanted to change physicians because the physician did not know the name of the medication the patient was taking. The physician did not have the medical records from the hospital and did not know the exact drug that the patient was placed on during the hospital visit. The patient came into the office and the physician did not know the name of the BP medication, so the patient got all upset and wanted to change physicians, I tried to explain it was just a matter of getting the records from the hospital, the patient still upset. When I asked the patient what he took, he stated, “I don’t know the name of it” I found that odd. I know the names of the medications that I take, and feel that patients should know the name of every pill they take and what it is for. The patient had been on the medication for 3 weeks and took it daily, but did not know the name. Patients have more responsibility for their health care than the physician does. This was just too crazy for me to understand. So I say to all patients know your own health history and be responsible with it.

Original Post:
March 4, 2008
While I am in strong agreement that inadequate systems are to blame for many of the errors made in medicine, I also believe that the culture of medicine is to blame. In order to protect themselves and their loved ones from such errors, patients must start taking some responsibility for their own health care. Nurses and doctors must welcome questions and provide adequate answers. I have taken care of that patient or family who was always questioning, always double and triple checking up on me and all of the other providers. I have also made errors, but not on that patient.

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Use of Magnesium Sulfate for Preterm Labor Can Have Potentially Lethal Consequences

January 16, 2008

Magnesium Sulfate has been used in pregnant women to help prevent preterm labor and delivery. It is also used in low doses in preeclampsia to prevent seizures. However, magnesium sulfate can be a very dangerous drug, even fatal, if given in too high of a dosage. In my experience, I have read stories about women receiving toxic levels of magnesium sulfate. As a result, the women went into respiratory arrest and died. This incident occurred because of a medication error made by the nurse. It should be understood by nurses who give patients magnesium sulfate to due so with caution. They should be educated on signs and symptoms of magnesium toxicity, which include, absence of reflexes, difficulty arousing the patient, respiratory depression, confusion, and cardiac depression. Lethal, as well as legal responsibility can be avoided with increased awareness of the potentially dangerous consequences of magnesium toxicity and overdose.

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