Medication administration errors occur across all aspects of the healthcare system in every setting. They are also committed by many medical professionals including nurses, doctors, and pharmacists. Medication errors can also happen at home when self administering prescription drugs. This is not a highly publicized part of healthcare, however when they do occur they can have life altering effects on the patients. Harm is most often the outcome, and although some things can be reversed, there are adverse effects that can not be fixed. Death is the ultimate bad outcome and it does happen. Medication errors can also lead to increased costs for the facility and patient. Thousands of dollars are added on to a patients hospital stay in response to a medication error. Often times these event lead to a longer hospitalization or need for an intensive care unit (ICU) stay.
There have been strides in recent years to prevent medication errors such as the report that was published “To Err is Human”, and the implementation of the five rights of medication administration.
The five rights of medication administration are:
- Right Patient
- Right Medication
- Right Dose
- Right Time
- Right Route
Recently, medical facilities have added to the five rights of medication administration independently based on observations and recorded errors that have occurred there. Even bigger strides were accomplished with the adaption of the barcode scanning system. However, this has not been universally adopted. In some areas of facilities that have turned to using barcode scanners they are still not used by every department. This leaves plenty of room for the continuation of medication errors. Electronic prescribing systems have become more popular in the last few years, and have reduced medication dispensing errors that can occur due to bad hand writing. The adoption of the online system also allows for more closer monitoring of allergies and drug interactions with previously prescribed medications.
One of the latest implementations is the need for dual sign offs on high risk medications. Two nurse verifications are required for medications such as insulin, heparin, and total parenteral nutrition (TPN). One of the highest rated medication errors occurs with the administration of insulin. The dual verification system has multiple steps such as verifying blood sugar levels and the amount of insulin in the syringe. Red warnings have also been placed on vials of high alert medications as a reminder that extra precaution should be taken with those drugs.
Lastly, and integral part of preventing further medication administration errors is to evaluate and learn from previous mistakes. Having an internal reporting system for all staff to be able to report errors should be put in place. In most systems the reporters and those involved can choose to stay anonymous. Having a culture where reporting errors is not punished and rather learned from could encourage more reporters. With all of these new interventions there were still hundreds of medication administration errors committed every day. The question is where are we not doing enough to prevent them?
References
Abuelsoud, N. (2018). Improving medication safety through implementation of medication error reporting systems in different medical specialities. Journal of Pharmacy Practice & Research, 48(6), 537-542.
Kavanagh, C. (2017). Medication governance: preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159–165.
Macias, M., Bernabeu-Andreu, F. A., Arribas, I., Navarro, F., & Baldominos, G. (2018). Impact of a barcode medication administration system on patient safety. Oncology Nursing Forum, 45(1), 1–13.
Hello,
This is a very informative blog post that covers a current topic in healthcare. I like how you mentioned how medication errors are not limited to occurring as hospitals and they can occur at home as well. You also mentioned the five rights which are used to reduce the incidence of medication errors. In addition to the five patient rights, you mentioned the more current solution of bar code scanning. I was not aware this was not a more widespread practice. You also mentioned the implementation of electronic prescriptions, dual sign offs and learning from past mistakes which show that healthcare is determined to reach a zero-harm model where there are no medication errors.
Hi,
I found your blog to be detailed and informative about the current problem we are facing in the medical field. Medication errors are costing us patient safety. As healthcare workers it is important we are always using the five patient rights in order to decrease a medication error from occurring. I believe dual sign offs for high risk medications is an amazing safety measure that works!