medication error
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School
Sault College *
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Course
101
Subject
Health Science
Date
Jun 12, 2024
Type
docx
Pages
6
Uploaded by ChefStingray4311
Trillium Health Partners
Unique
ID
HCL-MDCNEROR-2023-001
Risk (Description)
Condition
: Medication error in hospital setting (Trillium Health Partners) Cause
may be originating from any of the following:
Illegible handwritten prescription,
Incorrect drug given,
Incorrect dosage,
Incorrect route,
Omission,
Medications that sound alike,
Medications that look similar may be dispensed in error,
Medication given to a different patient, and
Medications administered with failure to check for contraindications or allergies (AMCP.org, n.d.)
Potential consequences
may be:
Impaired patient safety,
Employee sanctions (reprimanded, suspended or dismissed),
Professional discipline from governing body such as CNO for nurses (suspension, or license revocation),
Lawsuit, and
Additional expense from the business (CNPS, 2022)
Likelihood
(Probability)
According to the Canadian Patient Safety Institute, “medical errors account to 28,000 deaths yearly”, and that the most common errors are related to medication errors. This
may include errors in giving an incorrect medication, incorrect dosage, incorrect route, medication given to a different patient, or giving medication to patients with allergies or contraindications with other treatment regimen (Llp, n.d.). Impact
Patient and their family – medication error may lead to potential harm to patients ranging from non-notable effect to mortality. Some medication error may also potentiate for a new condition which may complicate the patient’s health condition further, or worst may lead to patient’s death. The family’s grief from the loss upon the patient’s death is already devastating, how much more to find out that it could have been prevented,
Healthcare practitioners – Nurses or even doctors who may have by accident committed a medication error may tend to experience self-doubt, shame, or guilt which
may lead to frustration, self-preservation like avoidance to report error incidents, additionally, an employee may be sanctioned for suspension, termination or even license revocation by its respective governing body in severe or repetitive cases, and
Hospital – Every healthcare organization’s aim is to provide the best health services and excellent patient experience through prioritizing patient’s safety. A healthcare organization is also a business that relies on income to be able to survive. If the number of cases related to medication error continue to rise, this mean more money will be lost from the organization from money spent for additional costs to reverse the effect of medication error, fines, or even lawsuits. The hospital’s reputation may also be impacted by unfortunate errors experienced by patients, thus may affect community’s trust, and opt to seek health services somewhere else (Qlicksmart_Admin, 2020).
RAG Status
RED (HIGH RISK)
Medication error is the most common medical error not only in Canada but also in other countries. The likelihood of its occurrence has a high probability and frequency, which may cause potential harm to patients ranging from non-notability to patient mortality. Any incident of medication error must be given priority for management, using root-cause analysis to identify the gravity of the impact to patient condition and to the business in the long run (Llp, n.d.).
Timescale
The risk window for medication error may happen at any point the medication process. This window begins from writing the prescription, processing the order, transcription, medication dispensing from the pharmacy, preparation of medication, to administering to patients. The risk window would depend on what stage of the process it occurred, what type of medication error occurred, the status of the patient, and what are the potential effect of the given medication to the patient (CNPS, 2022)
.
Cost
The individual cost of plan for adverse drug event in the US ranged from $3,408 to $6,941 depending on severity, that brings to an annual cost ranging from $0.9 million to $5.6 million. These costs are derived from necessary additional laboratory tests, longer hospital stays, other routine services, surgery, and other ancillary charges (Pan et al., 2015).
Owner
The health practitioner and the hospital own the responsibility, however, a specialized group of healthcare practitioners consisting nurses, doctors, pharmacists, personnel for quality assurance, and personnel for risk management will be closely monitoring and ensures that medications are correctly prescribed, processed, dispensed and administered (AMCP.org, n.d.).
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Risk Management Approach / Mitigating actions
Prevention actions:
Prior authorization – prior authorization is essential to be in place especially for high alert medications or for those with significantly high dosage or frequency,
Bar Coding – Electronic technology can help prevent incidents of medication error especially for those medication that sound alike or look alike. With the help of technology, it can be assured that the patient will be given the right medication especially with the help of bar coding where multiple information can be accessed about the drug by just scanning the bar code,
Electronic prescription Record – This is an effective way to eliminate errors arising from illegible handwritten prescriptions. Pharmacists can also be alarmed for contraindications or duplicate medications especially for patients receiving several medications,
Automated medication Dispensing – The technology of automated dispensing machines is used nowadays in hospitals. This ensures that right medications are dispensed which are specifically prescribed for the patient,
Internal Quality Control Procedure – Established protocols such as double-checking with another nurse for confirmation that the nurse have prepared the medication
correctly, with correct dosage, dilution and correct medication, and
Patient Education – Educating patients is as essential as educating the healthcare providers. Patients must have a clear understanding of what medications they are receiving and the purpose of such medications. In this way, patient taking a different medication may also be prevented (AMCP.org, n.d.).
Impact plan:
Seek for medical attention – after a medication error transpired, it is vital for the healthcare provider to report the incident and seek for medical assistance from physicians to correct the error immediately.
Assess the patient – It is of high importance to assess the patient for any untoward effect the error might have caused.
Admit the error – prompt reporting helps lessen the gravity or extent of the consequence of the error. It is essential for the healthcare provider to acknowledge the error and inform the patient, and the healthcare team managing the patient’s condition.
Document the error – Complete documentation is necessary to be in place especially in the patient’s record, and for the specialized group to perform a root-cause analysis and identify what step could have prevented the error for future use.
Conduct a root cause analysis – A root cause analysis is an essential step in mitigating and preventing future errors. This step identifies the underlying cause of the error and what steps could have prevented the error. It is an opportunity to review effectiveness of established protocol such as having another health practitioner double check the computation, the medication name and indication prior to administering.
Implement corrective actions – Corrective measures need to be put in action after the underlying cause has been identified to prevent it from reoccurring in the future. It is necessary to put emphasis on strict adherence to established protocols or modification if deemed necessary (Leask, 2021).
Residual
Risk
Eliminating the incidence of medication error in the hospital setting is a complex and challenging concern despite preventive measures are already in place because of factors such as human error, complexity of treatment regimen, and number of medications a patient is receiving. Hospitals like Trillium Health Partners continuously aim to reduce the incidence of medication error by continuous review of established protocols and updating as necessary.
Early Warning
Signs
Medication errors are more likely to occur during these scenarios:
Patient confusion
Changes in vital signs
Adverse reactions such as rashes, flushing, itchiness etc.
Medication discrepancy
Incomplete medication history such as unsigned medication in patient chart
Miscommunication among healthcare providers
References
Llp, N. (n.d.).
Medication Errors are Common in Canada - Medical Malpractice Lawyers
. Neinstein LLP Medical Malpractice
Lawyers.
https://medicalmalpractice.ca/news-blog/medication-errors/medication-errors-medical-malpractice-lawyers
AMCP.org. (n.d.). Medication errors | AMCP.org
. https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-
errors
cnps. (2022, August 11). InfoLAW: Medication errors - Canadian Nurses Protective Society
. Canadian Nurses Protective
Society. https://cnps.ca/article/medication-errors/
Qlicksmart_Admin. (2020, October 27). Impact of medication errors on patients, healthcare providers and hospitals
. Qlicksmart - Sharps Safety Solutions for
Surgical and Medical Professionals. https://www.qlicksmart.com/impact-medication-errors/?v=3e8d115eb4b3
Pan, J., Mays, R., Gill, S. L., Albert, N. M., Patel, D., Stephens, J., Rocha-Cunha, C., & Pulgar, S. (2015). Published costs of Medication errors leading to
preventable adverse Drug events in US Hospitals. Value in Health
. https://doi.org/10.1016/j.jval.2015.03.483
Leask, K. (2021, September 17). How to deal with medication errors. GPonline
. https://www.gponline.com/deal-medication-errors/article/1727689
Conclusion:
The table indicates detailed information regarding injuries from needle stick, medication errors and fall. These injuries usually occur in hospital settings such as Trillium Health
Partners, along with information associated with risks, and risk management strategies and mitigation. Needlestick injuries can also result in serious health implications,
psychological distress, and high costs, in the same way as medication error and falls. They are more likely to occur in healthcare settings with higher exposure risks and in cases
where safety protocols are not followed. Emphasizing prevention through safety measures, education, and the use of safety-conscious devices is very important. Hospitals and
healthcare workers share the same responsibility for managing this risk. While complete risk elimination is challenging, continuous monitoring, education, and the development
of safer practices and equipment are essential to reduce the residual risk to an acceptable level. In order to prevent these injuries, it is important to recognize early warning signs,
such as unsafe practices and gross negligence, is critical for preventing these injuries in healthcare settings.
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