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Sentara Tracking and Reporting System Form 

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Sentara Tracking and Reporting System Form 

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Why is nurse involvement the key factor for change?

Patient advocate

Last check for medication administration

Knowledge of policies and procedures

Training, education, and critical thinking knowledge acquired through experience and nursing school program

Resource availability

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Medication administration is the main task of the nursing team, requiring a considerable amount of knowledge (de Lima Gomes, Assis, Silva, Costa, Feijã, & Santos, 2016).

Medication errors are occurring at the patient's bedside when the medication is administered. The Registered Nurse is administering the medications, thus causing the error to occur.

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How Medication Administration Errors Occur

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  Inpatient Medication                     Administration Errors 

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  Inpatient Medication                     Administration Errors 

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Stephanie Ellis
NUR416: Capstone

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NUR: 311 Concepts of Pharmacology

NUR312: Medication Calculation and Adminstration

Assuming a professional leadership role

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Mandatory and enforced Omnicell/medication administration quiet zone

Patient to nurse ratio decrease

Electronic Medical Record and barcode system as a standard system throughout all hospitals

Further education for not only nurses, but also administrative staff, pharmacy, and other healthcare team members

Double-check system improvements

Decreasing fear of retribution for making mistakes

Higher staffing rates

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Noncompliance

Nurse burn out

Lack of time to implement interventions

Financial:

Lack of compensation for participating on councils

Fear of losing job and or being sued

Ethical:

Ethical decision whether or not to report the error

Social:

Fear of judgement, retribution from co-workers or management

Fear appearing incompetent

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        Analysis 1:                Nurses current role

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        Analysis 1:                Nurses current role

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How are nurses helping?

Medication administration error reporting

Participating on interdisciplinary teams

Members of councils that help create safety checks and bring attention to issues in the clinical field

How are nurses exacerbating the issue?

Skipping/overriding double check systems and barcodes

Under-reporting errors

Lack of education or critical thinking skills that are needed to detect an error has occurred

Not active members on present councils

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Medication administration has a large amount of steps that need to be followed in order to be executed correctly.

The steps include: Prescribing, transcribing, labeling, packaging, dispensing, distribution, administration, education, monitoring, and use (Alomari, Wilson, Davidson, & Lewis, 2015).

With the multi-step process of medication administration, anything can go wrong at any stage. Whether it be miscommunication between the physician prescribing and the actual administrator (nurse), or improper compounding in the pharmacy, there are many opportunities for something wrong to occur.

Nurses in particular are the last checkpoint before the patient is given a medication, which means the errors that are occurring can all be prevented with proper nursing skill, critical thinking, and execution. The medication error itself is occurring upon administration, which is completed by the nurse. Nurses are the patient's advocates; however, they are the ones that are allowing the medication error to actually occur.

Also, in addition to the multi-step process, the six patient rights of medication administration must be considered and applied for safe administration:

1. Right patient

2. Right dose

3. Right time

4. Right route

5. Right drug

6. Right recording of time

The errors are occurring when nurses fail to provide safe or accurate medication administration, due to many different causative factors.

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Inpatient hospital settings

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Medication administration errors occur due to many influential factors affecting nurses from being able to provide safe and holistic care.

There are many distractions, not only at the bedside but also while in the Omnicell room drawing up medications, strenuous, long shifts causing fatigue and decreased critical thinking ability, time restraints, miscommunication between health care providers, and overall a high amount of medications to administer to multiple patients.

Nurses are also becoming fairly comfortable in such a way that when administering high-risk medications such as heparin or a very common medication, Insulin, which requires a double-check by a second nurse to verify the right patient, dose, and medication, they are inserting fellow nurses initials into the EMR without them truly checking the medication.  Nurses are essentially trusting one another to administer the correct amount and type of medication prescribed to the correct patient.

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Why Are Medication Administration Errors Occurring

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Patients: All throughout the inpatient hospital setting.

Nurses: Disciplinary actions may be taken based on each facility and state's legal policies. We are the final checkpoint before patients consume the medication whether it is correct or not; therefore, we are the last ones that are able to prevent the medication error and harm from happening. Nurses are liable and held accountable for the medication administration error if one does occur.

Family members: Family's witness their loved ones becoming more sick or unfortunately they may pass away from a preventable error. They often put all of their trust and hope in the health care staff to properly care for their family member and this is not always provided.

Government: The government spending is considerably increased in relation to health care to over $1 trillion dollars to treat preventable medical injuries annually (Hung, Chu, Lee, & Hsiao, 2016). Although the government is definitely not the priority when considering medication administration error, it is directly affected from a financial standpoint.

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Inpatient hospital medication administration error.

Medication administration error is considered a preventable event, that we as nurses have the power to change and ensure safety for our patients.

Rates continue to rise despite interventions put into place due to lack of consistent implementation of safe practice by  nurses.

Are there new interventions that can be put into place? Should we be re-educating nurses and staff regarding those currently being used?