Medication errors

Please edit criteria 1,2,3 and help with apa

 

 

Lynne Brush  Applying Research Skill  Developing a Health Care Perspective   Applying Research Skills  2/6/2021                                                    Annotated Bibliography              Farag, A., Blegen, M., Gedney-Lose, A., Lose, D., & Perkhounkova, Y. (2017). Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. Journal of Emergency Nursing, 43(3), 246–254. doi: 10.1016/j.jen.2016.10.01  The authors in this article focused more on the nurse and the lack of reporting medication errors. Medication errors have risen to the third leading cause of death in the United States thus making it the most reoccurring error in healthcare (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017).  Nurses are confronted with a higher risk of medication errors occurring due to their increased workload, higher acuity level of patients, repeated disruptions, and time pressure. These factors further threaten the safety of patients during medication administration. According to the article, medication errors are estimated to occur 1 in every 4 medication administrations (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017). Though not all medication errors are harmful, 0.6% of medications errors are severe enough to either harm or kill the patient (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017). Fortunately, most errors are caught before administration has begun, this is called “near-misses.”   Nurses are the frontline for reporting medication errors. While most of the serious medication errors are reported by nurses, the minor errors and near-misses usually go unreported. The article suggests that the cause for under-reporting is partially due to fear of retaliation from upper management. Nurses in this situation may worry that they will receive criticism and be reprimanded for these mistakes. The authors propose that in order to increase the likelihood that a nurse reports all medication errors, the work environment must be supportive and prioritize a safety culture (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017). In creating an environment that focuses on safety, nurses and staff can use these events as a learning opportunity and therefore create policies and guidelines to prevent adverse drug events from occurring.   Härkänen, M., Tiainen, M., & Haatainen, K. (2017). Wrong-patient incidents during medication administrations. Journal of Clinical Nursing, 27(3-4), 715–724. doi: 10.1111/jocn.14021  In this journal entry, the authors draw attention to the misidentification of patients during medication administration, meaning the nurse fails to properly identify the patient before administering medications. These errors can easily be averted if the nurse utilized ‘the five rights’ of medication administration– the right patient, the right drug, the right dose, the right route, and the right time. Properly identifying the patient during each medication administration reduces the risk of medication errors. The article discusses a study involving 1,012 incident reports. 10% of those incidents were errors involving medications given to the wrong patient (Härkänen, Tiainen, & Haatainen, 2017). In most of the instances, the medications were given to a neighboring patient or patient in the same room (Härkänen, Tiainen, & Haatainen, 2017).  The article and study performed demonstrates the importance of accurately identifying patients to reduce the risk of medication errors.   Naunton, M., Nor, K., Bartholomaeus, A., Thomas, J., & Kosari, S. (2016). Case report of a medication error. Medicine, 95(28). doi: 10.1097/md.0000000000004186  I found this article interesting due to the recognition that many medications not only have similar names but also similar spelling and packaging. As reported by the World Health Organization, the most common reason recognized for medication errors is the complicated drug names (Naunton, Nor, Bartholomaeus, Thomas, & Kosari, 2016). The article discusses a case study that was done based on a patient receiving a scalp lotion in her eye instead of eye drops. The error was reportedly made due to the similarities in the labeling as well as both products being packaged in dropper bottles.  Many drug names look and sound alike, thus causing confusion during the ordering, preparing, and administration of medications. The authors pose that the similarities in packaging and labeling of medications causes misperceptions and therefore, increases the risk of an adverse drug event.   Learnings from the Research   Each article presented an additional cause for medication errors—failure to properly identify the patient, increased distractions in the workplace, and confusion surrounding the medication names and/or packaging. Due to my personal experience with the misadministration of medication, I have always felt that I hold medication error prevention to a higher standard for myself. Before administering any medications, I make sure to practice ‘the five rights’ of medication administration, confirm two patient identifiers, and verify medication orders if there is any confusion. However, after reading the article by Farag, A., Blegen, M., Gedney-Lose, A., Lose, D., & Perkhounkova, Y. (2017), I realized just how often and how easy it is to have a delay in tasks due to an interruption. Previously, I felt these distractions were minimal due to the nature of my work environment, but this article has reminded me that these disruptions can potentially lead to medication errors.  I have been disrupted several times during medication administration, whether it is by another patient, a phone call, another nurse, or even a doctor communicating with me.                              References    Farag, A., Blegen, M., Gedney-Lose, A., Lose, D., & Perkhounkova, Y. (2017). Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. Journal of Emergency Nursing, 43(3), 246–254. doi: 10.1016/j.jen.2016.10.015  Härkänen, M., Tiainen, M., & Haatainen, K. (2017). Wrong-patient incidents during medication administrations. Journal of Clinical Nursing, 27(3-4), 715–724. doi: 10.1111/jocn.14021  Naunton, M., Nor, K., Bartholomaeus, A., Thomas, J., & Kosari, S. (2016). Case report of a medication error. Medicine, 95(28). doi: 10.1097/md.0000000000004186          

Medication errors

Please edit criteria 1,2,3 and help with apa

 

 

Lynne Brush  Applying Research Skill  Developing a Health Care Perspective   Applying Research Skills  2/6/2021                                                    Annotated Bibliography              Farag, A., Blegen, M., Gedney-Lose, A., Lose, D., & Perkhounkova, Y. (2017). Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. Journal of Emergency Nursing, 43(3), 246–254. doi: 10.1016/j.jen.2016.10.01  The authors in this article focused more on the nurse and the lack of reporting medication errors. Medication errors have risen to the third leading cause of death in the United States thus making it the most reoccurring error in healthcare (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017).  Nurses are confronted with a higher risk of medication errors occurring due to their increased workload, higher acuity level of patients, repeated disruptions, and time pressure. These factors further threaten the safety of patients during medication administration. According to the article, medication errors are estimated to occur 1 in every 4 medication administrations (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017). Though not all medication errors are harmful, 0.6% of medications errors are severe enough to either harm or kill the patient (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017). Fortunately, most errors are caught before administration has begun, this is called “near-misses.”   Nurses are the frontline for reporting medication errors. While most of the serious medication errors are reported by nurses, the minor errors and near-misses usually go unreported. The article suggests that the cause for under-reporting is partially due to fear of retaliation from upper management. Nurses in this situation may worry that they will receive criticism and be reprimanded for these mistakes. The authors propose that in order to increase the likelihood that a nurse reports all medication errors, the work environment must be supportive and prioritize a safety culture (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017). In creating an environment that focuses on safety, nurses and staff can use these events as a learning opportunity and therefore create policies and guidelines to prevent adverse drug events from occurring.   Härkänen, M., Tiainen, M., & Haatainen, K. (2017). Wrong-patient incidents during medication administrations. Journal of Clinical Nursing, 27(3-4), 715–724. doi: 10.1111/jocn.14021  In this journal entry, the authors draw attention to the misidentification of patients during medication administration, meaning the nurse fails to properly identify the patient before administering medications. These errors can easily be averted if the nurse utilized ‘the five rights’ of medication administration– the right patient, the right drug, the right dose, the right route, and the right time. Properly identifying the patient during each medication administration reduces the risk of medication errors. The article discusses a study involving 1,012 incident reports. 10% of those incidents were errors involving medications given to the wrong patient (Härkänen, Tiainen, & Haatainen, 2017). In most of the instances, the medications were given to a neighboring patient or patient in the same room (Härkänen, Tiainen, & Haatainen, 2017).  The article and study performed demonstrates the importance of accurately identifying patients to reduce the risk of medication errors.   Naunton, M., Nor, K., Bartholomaeus, A., Thomas, J., & Kosari, S. (2016). Case report of a medication error. Medicine, 95(28). doi: 10.1097/md.0000000000004186  I found this article interesting due to the recognition that many medications not only have similar names but also similar spelling and packaging. As reported by the World Health Organization, the most common reason recognized for medication errors is the complicated drug names (Naunton, Nor, Bartholomaeus, Thomas, & Kosari, 2016). The article discusses a case study that was done based on a patient receiving a scalp lotion in her eye instead of eye drops. The error was reportedly made due to the similarities in the labeling as well as both products being packaged in dropper bottles.  Many drug names look and sound alike, thus causing confusion during the ordering, preparing, and administration of medications. The authors pose that the similarities in packaging and labeling of medications causes misperceptions and therefore, increases the risk of an adverse drug event.   Learnings from the Research   Each article presented an additional cause for medication errors—failure to properly identify the patient, increased distractions in the workplace, and confusion surrounding the medication names and/or packaging. Due to my personal experience with the misadministration of medication, I have always felt that I hold medication error prevention to a higher standard for myself. Before administering any medications, I make sure to practice ‘the five rights’ of medication administration, confirm two patient identifiers, and verify medication orders if there is any confusion. However, after reading the article by Farag, A., Blegen, M., Gedney-Lose, A., Lose, D., & Perkhounkova, Y. (2017), I realized just how often and how easy it is to have a delay in tasks due to an interruption. Previously, I felt these distractions were minimal due to the nature of my work environment, but this article has reminded me that these disruptions can potentially lead to medication errors.  I have been disrupted several times during medication administration, whether it is by another patient, a phone call, another nurse, or even a doctor communicating with me.                              References    Farag, A., Blegen, M., Gedney-Lose, A., Lose, D., & Perkhounkova, Y. (2017). Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. Journal of Emergency Nursing, 43(3), 246–254. doi: 10.1016/j.jen.2016.10.015  Härkänen, M., Tiainen, M., & Haatainen, K. (2017). Wrong-patient incidents during medication administrations. Journal of Clinical Nursing, 27(3-4), 715–724. doi: 10.1111/jocn.14021  Naunton, M., Nor, K., Bartholomaeus, A., Thomas, J., & Kosari, S. (2016). Case report of a medication error. Medicine, 95(28). doi: 10.1097/md.0000000000004186          

0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *