Posts Tagged ‘Medication Errors’

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Pediatric medication errors

October 7, 2008

In regard to Medical neglect on April 30, 2008: I perceive weight miscalculations recognized as a frequent problem in medication dosaging. I would encourage nurses to have the child’s weight double checked by the parent and another nurse.

Original Post:
April 30, 2008
The reading I would like to comment on is Compliance and Noncompliance. This is an issue for many different reasons in any healthcare setting. In the setting that I work (the pediatric outpatient clinic serving mainly low socioeconomic families) noncompliance usually goes hand and hand with medical neglect. A large percentage of our population is of African American decent. I do know that there are some culture beliefs on medical care. The idea of preventive care, for example with well child visits is not seen as a necessity. Taking the time to educate on why preventive care is necessary and can help avoid medical problems is the only way to decrease the noncompliance rate. However a large part of my job is to also monitor appropriate follow up for medical concerns. The compliance rate goes down when people feel that their child is better from their illness. Asthma is chronic diseases where I see parents bring their child to the ER in an asthma exacerbation only to not show for their pulmonary follow up because the child was not wheezing anymore. It is our responsibility to take these opportunities and teach why it is so important to follow up with pulmonary care. The education to the parent that you may not hear anymore wheezing does not mean that the child is not still having problems. Proactive patient education can help with compliance and noncompliance rates.

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Medication errors

October 2, 2008

The nurse ”is the last line of defense” in preventing medication errors. One must read and reread and recheck all labels. In light of many errors in dosing recently in relation to the medication Heparin, one must read and reread and recheck all labels. The vials of Heparin state 1 unit dose. A nurse you must check and recheck the orders, the dose, the patient, on all medications, If medication is prepared by the pharmacy, we must not take it for granted the mixture of medications is correct. We must be careful in rushing to give medication, must check and recheck everything, before administering any medication, Errors, do happen as nurses we are the last line of defense to catch these errors.

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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 Errors, comment

September 17, 2008

I don’t think medication errors are being reported as much as they occur. Nurses have a tendency not to report for fear of disciplinary action. We need a way to assure the nurse that she/he will not receive discipline but allow them to take the experience to learn from. To provide quality care we must report these incidents. I have always felt that if I make a mistake and no harm has come to anyone this is an opportunity for me to grow and share the experience with others. I feel even the smallest medication error should be reported so we can do a root/cause/analysis to improve the process so that the same error doesn’t happen again. It is my responsibility to report any error that I make to assure the safety of my patients. No one is perfect but we need to take responsibility for our actions.

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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Six rights of drug administration, comment

August 21, 2008

The 6 rights of drug administration did not prevent the cause of death. The problem lies with the incorrect labeling of medication. The key is to trace what happened, review for any outlying causes or “what happened” and correct that as soon as possible. While the nurse I am sure will have to live with that the rest of her life, and that’s not easy, I feel that she has comfort in knowing she did not cause this. Many hospitals are using the computerized medical dispenser where you scan the patients ID bracelets then you scan the drug that is being administered which is on a time schedule also. The thinking is this will correct and help make sure the 6 rights of drug administration are followed, while this looks good for JACHO, the bottom line is a human is still keying in the information and we all make mistakes. I am not so sure the technology we have today in practice is as good as the old fashion, “know your patient and the medications being administered”.

Original Post:
Feb. 26, 2008
Adhering to the 6 right of medication administration is really the only sure way of preventing medication errors the best way we can. As a nurse who works on very busy and fast-paced area, it is very easy to overlook the 6 rights, especially when you are pulling meds from a medication-dispensing machine. An incident similar to this one occurred on my unit not too long ago. Fortunately, it did not result in patient harm or death. Misoprostil is used on my unit for cervical ripening. The M.D. ordered for the nurse to place 25mcg of misoprostil. The tablets normally come in 100mcg or 200mcg form. As far as everyone knew, we never had 200mcg tablets. The nurse pulled a 200mcg tablet, and without looking at the label, cut the tablet into 4’s. The patient ended up getting twice the correct dose. The pharmacy had stocked the wrong amount even though the nurse thought she was getting 100mcg. So, it is very important to read labels on medication prior to giving them to the patient, even if you think you are getting the right thing.

Original Post:
September 24, 2007
In 2006, a Wisconsin nurse administered the incorrect medication to a 16-year old girl who was in labor. The medication killed the girl almost instantly. The nurse had been working in the field for 15 years and was described as very competent. Following this incident, it was determined that the medication was labeled incorrectly. The nurse was subsequently charged with involuntary manslaughter.

In reading about the 6 Rights of Drug Administration, I couldn’t help but think of this case and so many other cases with similar circumstances. Any system is going to have flaws as humans are the ones designing the system and entering the data into the system. The 6 Rights can be adhered to, which will greatly reduce these types of occurrences, but they won’t be eliminated.

The charges against the nurse were dropped, but it’s something that she will have to live with for the rest of her life…that’s more punishment than any court could have imposed on her.

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Nurse To Patient Ratios, comment

April 10, 2008

It is true that the nurse to patient ratio is not fare to nurses or patients. But how about the fact that nurses are called off when the census goes down and there is not enough patient per nurse? The same nurse has to take off when census is down and use her/his PDO, which was earned over a period with hard work.

My question is why not let the same nurse work with less pt that day or that night and give the nurse a chance to catch her breath for those busy time that she even did not have time to take a lunch break or go to the bathroom in 8 or 12 hrs shifts? Why don’t make them educate the nursing assistants that they are there to help and make them CNA (certified nursing assistance)? Why the same nurse who had 8 to 10 patient can not work on the days the census is down? Why should the ratio be 2:1 in ICU which was the case in two local hospitals I have worked, but in step-down the ratio is 1 nurse to 5 pts. In step down unit if the censes goes down and ratio become 2 to 3 patient a nurse will be cancel and are called extra nurses. In my humble opinion as an experienced nurse, it is not important how much less patients you have it is the acuity that is important. Nurses are dealing with the person’s life. Patients and nurses are humans they not object. Hospitals and care organizations are 24/7 they are not a department store that open and closes in certain hours, they can not tell the patient sorry we are going to close in ½ hr you should not have chest pain now, you have to wait, nursing is a matter of life and death and they should be treated as partners in this endeavor.

This practice causes nurses to move around for more equitable pay, and leaving their own place where the patients need them, which has given rise to nursing shortage, but with more traveling and agency nursing for temporary assignments. Another drawback to this is that local nurses who take care of patients with the same standard are unhappy because they are working under the same condition with the same patient ratio and getting paid less. There seems to be no justification to make nurses satisfied as far as these issues are not solved. May be some of the hospitals should reduce the
manager to nurse ratio and not waist nursing staff to management so much. Let nurses do nursing job and take care of patients not spend long hours in meetings and unnecessary paper work. Of course patients deserve best and safe care no matter where they are with justified and fair patient to nurse
ratio.

Original Post:
September 19, 2007
There are 2 distinct sides to one of the most controversial dilemmas facing nurses today. First, the patients deserve to have better care from their nurses who don’t already have 9 other patients to take care of. If a nurse is responsible for 8-10 patients on a typical med-surg floor how can they be expected to provide the best possible care, or even just the standard of care? The more you spread a nurse out the less attention one single patient is going to receive. This puts them at greater risk for nosocomial infections, medication errors, incorrect or omitted assessments, the list could goes on. Even if a super nurse is able to accomplish this inhuman standard in their occupation what harm will be done to the nurse? A nurse, the backbone of the medical industry, does not deserve to be worked like a dog, to put these kinds of physical and mental demands that ultimately will harm their ability to take care of themselves and their patients. A standard in setting how many patients a nurse can be assigned to is a top priority for are already overworked nurse workforce.
Of course, you have valid arguments provided by hospital administrators and government agencies, but they are not strong enough arguments to persuade this nurse to think any different. The costs are too high, there aren’t enough nurses to staff this way. This is the mentality the non-nurses elect to have. If there are not enough nurses to staff a set ratio then it just supports the fact that nurses should be respected and not overworked to the point where they have to quit nursing. When aspiring nurses see how very little the hospital administrators actually care for their then the smart ones will choose another field and only add to the nursing shortage. The costs are high now because of law suits and problems that arise from not having a healthy ratio standard in place. By reducing errors caused now by not staffing patients well should reduce the unexpected costs that hospitals have to eat on a regular basis.
Really when it comes right down to it the golden rule should be considered by all. Would you want to be just another vulnerable patient that is one of 10 total care patients that the same nurse has to juggle?

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Male Nurses

April 9, 2008

Having worked in the nursing profession for 16 years, I have had the opportunity to work with male nurses. I confess that my initial reaction to this concept was anything but welcoming. Human nature tends to dictate that men are non-emotional beings. They are the hunters and the defenders of their domain. The strong silent species; using the right side of there brain; reacting to the here and now. How could such a being be a nurse? I look back on this now and acknowledge that this is a chauvinistic view point. I’ve come to realize that these are the same characteristics that have helped me to be the nurse that I am today. I’ve acted in a non-emotional way to crisis. I’ve hunted down doctors to meet my patients’ needs. I’ve defended my patients’ rites to receive or refuse treatment. I’ve stood strong in the wake of multitasking. I’ve been silent when listening to my patients concerns. I’ve even reacted professionally to a doctors comment of “here we go again” and “what the heck do you want now?” So, there in-lies the synergistic relationship between male characteristics and the nursing profession. They fit in just right!

Original Post:
August 28, 2007
It is estimated that by the year 2010, we will need one million new nurses. Where will these come from? One answer may lie with changing the traditional role of nursing. Nursing has always been primarily female. With more opportunities open to females now, no as many women choose nursing. This is adding to the nursing shortage and the nursing faculty shortage. As long as there is a shortage, more nurses will burn out and make more medication errors. With the field becoming more appealing to men, maybe they are our answer. The pay is certainly good as well as the opportunities and diversity. The only way to decrease med errors is for the nurses not to be overworked. The only way to accomplish this is to find more nurses. Male nurses may be the answer.

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Medication Errors Reduced

April 1, 2008

Medication errors has been greatly reduced as a increased awareness of both the nurse who actually gives the medications and the hospitals providing the financial backing to provide the nurse with computer assisted medication dispensing machines.
The potential for a medication error is greatly reduced by the use of computer order entry from the original person ordering the medication to the person administering the medication and all the steps in-between. With the physician using order entry directly into a computer program potential errors are flagged immediately for review of the prescribing physician. The pharmacist is no longer trying to guess what the chicken scratch is really saying or if the dosage is written incorrectly. The nurse uses computer assisted dispensing cabinets and in some cases bar coding of medications to assist in the prevention of the wrong medication being given.
Despite all this high technical devices that are available mistakes still happen and medication errors happen but not nearly as many as occurred when I first started nursing and we poured from bulk bottles and hoped in our frazzled world that we grabbed the right bottle. We also hoped that the physician had proper rest and wrote down the correct dosage to give the patient.
Computers, education, ready accessible reference books have been the reason that we have seen a reduction in medication errors. Singularly any one of these items can and does reduce the potential for errors but packaged together they form a safety net for all involved. Mistakes will still be made but hopefully they will become a thing of the past.

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Medication Errors

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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Medication Error, comment

February 26, 2008

Adhering to the 6 right of medication administration is really the only sure way of preventing medication errors the best way we can. As a nurse who works on very busy and fast-paced area, it is very easy to overlook the 6 rights, especially when you are pulling meds from a medication-dispensing machine. An incident similar to this one occurred on my unit not too long ago. Fortunately, it did not result in patient harm or death. Misoprostil is used on my unit for cervical ripening. The M.D. ordered for the nurse to place 25mcg of misoprostil. The tablets normally come in 100mcg or 200mcg form. As far as everyone knew, we never had 200mcg tablets. The nurse pulled a 200mcg tablet, and without looking at the label, cut the tablet into 4’s. The patient ended up getting twice the correct dose. The pharmacy had stocked the wrong amount even though the nurse thought she was getting 100mcg. So, it is very important to read labels on medication prior to giving them to the patient, even if you think you are getting the right thing.

Original Post:
September 24, 2007
In 2006, a Wisconsin nurse administered the incorrect medication to a 16-year old girl who was in labor. The medication killed the girl almost instantly. The nurse had been working in the field for 15 years and was described as very competent. Following this incident, it was determined that the medication was labeled incorrectly. The nurse was subsequently charged with involuntary manslaughter.

In reading about the 6 Rights of Drug Administration, I couldn’t help but think of this case and so many other cases with similar circumstances. Any system is going to have flaws as humans are the ones designing the system and entering the data into the system. The 6 Rights can be adhered to, which will greatly reduce these types of occurrences, but they won’t be eliminated.

The charges against the nurse were dropped, but it’s something that she will have to live with for the rest of her life…that’s more punishment than any court could have imposed on her.

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