Capstone2017_MedicationAdministrationError_StephanieEllis by Stephanie Ellis https://padlet.com/sellis20/kx6xdea1eybf Medication administration error in the healthcare field and how nurses play a huge role. en-us 2017-04-16 20:48:15 UTC 2023-05-16 03:16:02 UTC hello@padlet.com https://padlet-assets.s3.amazonaws.com/icons/Hearts.png Issue sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166482593
  • 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?

    • ]]>     2017-04-16 20:52:50 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166482593     Who is directly affected? sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166482597
  • 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. 
    • ]]>     2017-04-16 20:53:07 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166482597     Why are they occurring? sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166482621
  • 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.
    • ]]>     2017-04-16 20:53:55 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166482621     Where? sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166482630
  • Inpatient hospital settings
    • ]]>     2017-04-16 20:54:04 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166482630     When are they occurring? sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166491658
  • 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. 

    • ]]>     2017-04-17 01:09:20 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166491658     Literature review sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166491680 2017-04-17 01:09:48 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166491680 Analysis 1: Nurses current role sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166491690    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

    ]]>     2017-04-17 01:10:00 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166491690     Analysis 3: Barriers sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166491742
  • 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
    • ]]>     2017-04-17 01:11:32 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166491742     Recommendations sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166491800
  • 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
    • ]]>     2017-04-17 01:12:51 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166491800     Reflection sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166491813
  • NUR: 311 Concepts of Pharmacology
  • NUR312: Medication Calculation and Adminstration 
  • Assuming a professional leadership role
    • ]]>     2017-04-17 01:13:11 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166491813     Inpatient Medication Administration Errors sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/166493451 Stephanie Ellis
          NUR416: Capstone ]]>     2017-04-17 01:38:03 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/166493451     References sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/167557009 2017-04-21 17:57:26 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/167557009 How are they occurring? sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/167598159
  • 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. 

    • ]]>     2017-04-22 01:07:58 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/167598159     Introduction sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/167598458 2017-04-22 01:21:16 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/167598458 Conclusion sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/167598465 2017-04-22 01:21:42 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/167598465 Analysis 2: sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/167686793 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


    ]]>     2017-04-23 15:19:17 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/167686793     Sentara Tracking and Reporting System Form sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/168762184 2017-04-27 21:18:34 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/168762184 sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/168762761 2017-04-27 21:22:57 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/168762761 sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/168762951 2017-04-27 21:24:32 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/168762951 sellis20 https://padlet.com/sellis20/kx6xdea1eybf/wish/168763999 2017-04-27 21:33:28 UTC https://padlet.com/sellis20/kx6xdea1eybf/wish/168763999