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Why I chose this topic:

Nurses administer medications daily

Medication errors can

Patient safety is a major priority in nursing

Josie's Story

Patient Safety:

According to the World Health Organization (WHO), "patient safety is the absence of preventable harm to a patient during the process of health care. In 1999, the Institute of Medicine (IOM) released its landmark report, To Err is Human. The report revealed that between 44,000 and 98,000 people died each year in United States hospitals due to medical errors and adverse events. The report went on to say that errors are caused by faulty systems, processes, and conditions, that lead people to make mistakes or fail to prevent them" (Institute for Healthcare Improvement [IHI], 2016).

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What is the problem?
According to Marvanova & Henkel, "a medication error is defined as one or more preventable mistakes made during prescription, transcription, dispensing, and administration of medication, potentially leading to inappropriate or, in the worst case, unsafe medication use" (2018).

Who is affected?
Both nurses and patients are directly affected by medication errors. "Although patients remain obvious victims, nurses who make medication errors, especially ones that could harm the patient, suffer feelings of guild and fear of loss of confidence and/or disciplinary action" (Agyemang & While, 2010).

How?
According to Johns Hopkins, medication errors "represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or under-use of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability" (2016).

Where?
Like stated previously, both nurses and patients are affected by medication errors (Agyemang & While, 2010). These errors can occur in any health care setting such as hospitals, nursing homes, home health, etc.

When?
Medication errors can occur at any time medication is administered to patients. "Medication administration errors are one of the highest risk areas in nursing practice, making the 'five rights' of administration (right medication, right dose, right route, right time, and right patient) the cornerstone of nursing."

Why?
There are many factors contributing to a medication administration error. There are personal factors including policy and procedures, such as second-checker not checking everything properly; stress and tiredness; and knowledge of medication such as deficits in preparing and administering medications. There are also organizational factors including distractions and interruptions; medication delivery systems; quality of prescriptions; heavy workload and multitasking; and design of technology (Agyemang & While, 2010).

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Direct Adverse Outcomes Related to Medication Errors

Injuries resulting from the use of a drug

Prolonged hospital stay

Additional resource utilization

Time away from work

Lower patient satisfaction

Death

The Impact of Medication Errors on Healthcare Systems

Scope of Errors

Annually in the U.S., serious preventable medication errors occur in 3.8 million inpatient admissions.

The Institute of Medicine, in its report To Err is Human, estimated 7,000 deaths in the U.S., each year due to preventable medication errors.

Expense

Inpatient preventable medication errors cost approximately $16.4 billion annually.

About $21 billion is spent annually on preventable medication errors; this includes all healthcare settings.

In events where patients die from medication errors, there is an increase in law suits.

Prescription Errors

Dosing errors make up 37% of all preventable medication errors.

Approximately 100 undetected dispensing errors can occur daily as a result of the significant volume of medications dispensed

(NEHI, 2008).

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Drug administration is an important role in nursing and nurses have the responsibility to check the medication prior to administration. This includes:

Checking the five rights of medication administration (right medication, right dose, right route, right time, and right patient).

Knowing when to administer or withhold medication to patients (for example, if a patient's heart rate is 50 beats per minute, a nurse should know to hold a beta blocker).

Double checking of medications, such as insulin, heparin drips, and patient-controlled analgesia (PCA) pumps, with another nurse

(Agyemang & While, 2010).

Nurses have the responsibility to report any medication errors; however, some nurses are afraid to report errors out of fear of litigation.

Is this improving or worsening the issue?
When nurses follow through with these responsibilities, it helps to improve the issue of medication errors. However, not all nurses follow through with these responsibilities which contributes to worsening of the issue. When nurses report medication errors, it allows the healthcare system to work on ways to prevent it from happening again and maintains patient safety. However, when nurses fail to report medication errors, it continues to put patients at risk. When nurses feel they are able to report medication errors without litigation, it will help improve the issue by preventing future errors. Also, when nurses fail to check the five rights of medication administration and assess their patient's health status prior to administering medications, such as beta blockers and insulin, it puts the patient at risk which contributes to worsening of the issue.
Therefore, the nurses that follow their facility's protocols, helps to improve this issue. However, the nurses that do not follow these protocols contribute to worsening of this issue resulting in increased risk for medication errors and putting their patients at risk.

Attached is Sentara Healthcare's protocol for medication administration (Morris, 2019).

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Analysis: Importance of Nurse's Involvement 

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Analysis: Importance of Nurse's Involvement 

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"Patient safety is a core nursing duty. Creating a safer healthcare system will depend on the ability of all nurses to fully use their education, expertise, and role to identify, interrupt, and correct medical errors to prevent patient harm" (Gaffney, Hatcher, Milligan, & Trickey, 2016). The more nurses are involved in this process, it should improve the problem of medication errors. "Medical errors are not typically caused by a negligent or incompetent healthcare professional. Instead they are often the result of a breakdown in processes that guide delivery of patient care" (Sorrell, 2017). Nurses have the responsibility to be advocates for their patients. They can advocate by bringing forward issues they have in the processes of medication administration to prevent future medication errors from occurring.

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The nurse is already highly involved in medication administration; however, there are several ways the nurse can participate to further prevent medication errors.

1. Patient Education:
Educating our patients is a major nursing responsibility. Patients need to be educated on their rights and responsibilities of medication administration as well.

"About 1/3 of adults in the United States take five or more medications." Patients should be aware of the medications they are being given and should question any medication they are unsure about.

Patients have the right to autonomy. Patients have the right to refuse medication and have the right to be educated about their medications.

Patients should be educated about being their own personal advocate during medication administration and to speak up if something doesn't sound right. Patients should also call their healthcare provider if they have any questions or concerns about their medications.

Educate patients on the importance of taking their medications as prescribed. To ensure patients take their medications at the right time, educate patients to utilize a medication organizer.

(Agency for Healthcare Research and Quality [AHRQ], 2019).

2.Continuing Nurse Education:
Nurses need to continue to be educated on strategies to help reduce/prevent medication errors.

Minimize interruptions during medication administration, which includes pulling medications from the omnicelle (AHRQ, 2019).

Finish one task at a time; the nurse should finish administering all medications to their patient prior to going to another task with another patient.

Nurses should take time to review what their patients vital signs and lab values are prior to administering medications.

Nurses should ensure they get another nurse to double-check high-risk medications.

When administering medications, nurses should tell their patients what medications they are being given

(Sorrell, 2017).

Speak up:  as a nurse, "if you see another member of the healthcare team do something that puts the patient's safety at risk, you should speak up. In most cases, patients do not feel like they have a voice, or are not able to detect an impending catastrophe. Without you (the nurse), a patient may have no voice."

Four behaviors to improve patient safety regarding medication administration:

Follow safety protocols

Speak up when you have concerns

Listen to patients, colleagues, and mentors

Take care of yourself

(IHI, 2016).

Obtain a bag for each patient to put their medications in to ensure you are administering the correct medications to the correct patient

3. Advocate for Healthcare System Improvement:
"Medical errors are not typically caused by a negligent or incompetent healthcare professional. Instead they are often the result of a breakdown in processes that guide delivery of patient care" (Sorrell, 2017).

"Healthcare organizations can take a learning approach to responding to error and unintended events. By examining the events that led to an error, health systems can look for reasonable system changes that could prevent the error from happening again. They can make changes that might identify when an error has occurred, so it can be intercepted before reaching the patient. With these changes, organizations can reduce the likelihood that such an error could recur or harm the patient" (IHI, 2016). Therefore, it is the nurse's responsibility to advocate for improvements in medication administration in their current healthcare system.

Storytelling is a way to help others understand medical errors. "Storytelling shifts thinking from 'rational and scientific' patterns to reflective thought that calls forth a detailed context surrounding that experience. Storying an experience of a medical error helps the narrator and 'listeners' to come to know, understand, and make sense of the experience" (Sorrell, 2017).

Reporting errors: "the prevention of medical errors within an organization requires systematic management strategies. Healthcare providers need education to understand the importance of reporting medical errors. Nurses in all settings need education and training to develop a shared definition of harm and understand the process for reporting errors" (Sorrell, 2017).

Blame-free approach: "In healthcare, it is important to differentiate between unintentional situations and deliberate ones. David Marx, a lawyer and engineer, developed the concept of a 'just culture' to describe the ideal system of accountability in a high-risk industry like healthcare. A just culture holds individuals to account for reckless behavior, while also recognizing that people make mistakes and aren't responsible for system failures" (IHI, 2016). If more healthcare organizations utilize a blame-free approach/just culture, it would allow nurses to be more willing to report medication errors. Therefore, nurses should help advocate for a just-culture in their healthcare environment to help prevent medication errors.

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Nurses are participating in medication administration; however, there are some challenges and barriers during this process.

Challenges:

Nurses often work long hours and are understaffed. When this occurs, nurses are limited on time with each patient and feel rushed with nursing tasks.

Nurses develop trust amongst each other, and decide to get medication double-checks from a nurse that is their "close friend" and end up not getting an accurate double-check; or other nurses are busy and don't have time to double-check the medication that needs to be administered.

Barriers:

Failure to report medication errors out of fear of litigation.

Knowledge deficit in preparing and administering medications

(Sorrell, 2017).

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Two Curricular Concepts:
1. Five Rights of Medication Administration:

Nurses have the responsibility to check the five rights of medication administration (right medication, right dose, right route, right time, and right patient).

Right Medication - Nurses have the responsibility to ensure they are administering the right medications to patients. "The Institute for Safe Medication Practices maintains a list of high-alert medications - medications that have dangerous adverse effects, but also include look-alike and sound-alike medications: those that have similar names and physical appearance but completely different pharmaceutical properties" (AHRQ, 2019).

Right dose - Nurses need to pay attention whether they need to calculate safe dosages for their patients, and if they are unsure of their calculations, they need to ask another nurse to double check their calculations.

Right Patient - Nurses should utilize two separate patient identifiers, such as name, date of birth, or medical record number, to accurately identify a patient prior to administering medication (IHI, 2016).

Utilizing these five rights of medication administration allows nurses to promote patient safety.

2. Importance of Double-Checking Medications:
"Double checking is a standard practice intended to improve patient safety, especially during medication administration." Insulin is a good example of a medication that needs to be double-checked by two nurses prior to administration.

Once the nurse draws up the insulin in the syringe, she should hand another nurse the syringe and the insulin bottle. She should ask the other nurse how much insulin is in the syringe to ensure she drew up the correct amount of the correct type of insulin that was ordered.

When utilizing the sliding scale for insulin, when getting a second-check, the nurse should tell the other nurse what this patient's blood sugar level was, to help ensure this patient gets the correct dose of insulin.

The nurse should use a nurse she is best friends with (since this friend trusts the nurse); instead, the nurse should use a nurse she isn't close with to verify the insulin to ensure it is the correct dose.

Nurses should take the time to double-check high risk medications, such as insulin, to help reduce the risk of medication errors from occurring.

"Patient deaths have been attributed in part to a failed double-checking process." Therefore, double-checking high risk medications is an important responsibility for nurses

(Hewitt, Chreim, & Forster, 2015).

Leadership Role:
These two concepts I have learned during my education at Sentara College of Health Sciences (SCOHS) has prepared me to take a leadership role once I transition to professional practice.

Be an advocate for my patients - Report medication errors and notify the patient's physician when there is an error in their prescription; nurses should also advocate for their patient's safety in regards to medications

Have a questioning attitude when administering medications; Speak up if you have concerns about the medication, route, dose, etc. to help prevent a medication error from occurring. Also, speak up if an error occurs to help prevent the error from occurring again.

Develop critical thinking skills to interpret interactions of medications administered and when to hold certain medications, such as beta blockers when my patient's heart rate is below 60 beats per minute

Promote patient safety by following the five rights of medication administration

Educate my patients, their family members, etc. about their medications