Medication Errors Essay Example

Medication Errors Essay Medication Errors Risk Management of Medication Errors. Risk management as concerns medication errors is the consistent improvement of the quality and delivery of medication to patients with consideration to safety. Consideration to safety involves the identification of situations that may put patients at risk and putting measures in place to prevent and control these risks. Key components of effective risk management include effective policies and procedures, documentation of patient care and other clinical activities as well as timely and transparent reporting of critical incidents (Marshall, 2011). Medication errors are often the result of various weaknesses in complicated medical system. The solution to this problem, therefore, has to involve the participation of all concerned parties including medical personnel and patients. Communication channels serving personnel involved in the medication process also need assessment. We will write a custom essay sample on Medication Errors specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Medication Errors specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Medication Errors specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Steps in Place Addressing Medication Errors at the Cleveland Clinic Hospital A number of procedures and policies were set up at the Cleveland hospital to prevent the repeated occurrence of medication errors. This involved setting up procedures and practices that govern handling of medication. Some of the best practices discussed and implemented to solve this problem include setting a zero-error goal in medication labeling. Erroneous labeling occurs during the removal of medication from its original packaging and placed into pre-labeled on unlabeled syringes or containers. Procedures implemented to counter this include ensuring the labeling of new containers immediately before or after transfer of the liquid because health care workers are prone to interruptions. Nurses take this precaution even when filling multiple containers with the same medication or solution. The nurses label these containers one type of medication at a time. The label should include the name, amount concentration, and expiration date of the solution. The entire staff involved in drug administration usually discards any unlabelled medication and if preparing medication but not administering it, they verify the label’s accuracy before using it. Labeling of multiple dose vials occurs after they are opening them. The label should indicate a 28-day expiration date. Scheduled audits of medication storage areas to remove expired medication occur regularly. Surprise audits of medical refrigerators and other storage areas also help in implementation, thus reducing the margin of error. Putting reminders such as ‘check label’ for medications reduces errors even among patients taking their daily dosage themselves. The security of medication is also of paramount importance to the Cleveland clinic. Security strictly restricts access to medication storage areas so only. The hospital constantly monitors storage areas without electronic or mechanical locks. The staff also secures and documents emergency medication kits both before and after an emergency to prevent access by unauthorized personnel. Another way of ensuring the safety of medication in storage at the clinic is the digital thermometer alarm attached to medication refrigerators that ensure temperature stays within the recommended range. Commonly confused medications such as DOBUTamine, DOPamine are often sources of confusion and consequently errors (Lippincott Lippincott, 2008). The Cleveland clinic instituted ‘tall man lettering’, a combination of upper and lower case letter to reduce confusion among these medications. The regulators also added â€Å"LASA† designation to these medicines, which have a separate storage area in the pharmacy. Online support for the use of LASA medication is available to the Cleveland clinic personnel. The management of high-risk medication such as insulin has reduced the margin of error usually prone to these types of medication. Vials of insulin removed from the floor stock are patient specific. Afterwards, nurses label the vials with patient’s details and the 28-day expiration date. They also put insulin and other high-risk medication such as anti-coagulants, chemotherapy, opioids, and concentrated electrolytes in separate storage and only authorized personnel can prescribe such medication with independent double-checking before administration. The staff thereby keeps these medications in standardized concentrations. Agency Solutions to Remedy the Medication Error Problem The Quality and Patient Safety Institute advises the Cleveland clinic on health safety and risk management. The agency came up with ways of incorporating safety into the hospital system to manage the error issue. Solutions have included the streamlining of hospital practices to those recommended by recognized regulatory bodies, which has led to accreditation clinic. Production of regular quality performance reports and continual process of improvements has enabled compliance and the participation of personnel. Another significant breakthrough instituted by the agency is the patient safety program, which has enabled patients to have a say in the safety aspects affecting treatment. It has also educated them on medication safety and promoted a spirit of cooperation in improving medication safety. Methods adopted by other facilities to address Medication Errors The consequences of medication errors have resulted in hospitals across the United States taking proactive steps to counter the occurrence of medication errors. Methods adopted include the use of standardized order sets for routine prescriptions and procedures (Sullivan Decker, 2005). An example is infusion pumps used to administer medicine. This reduces the need for handwriting, which is a major cause of errors and simplifies the treatment process. Environmental factors such as fatigue, long working hours, noise, and poor lighting in medical workplaces are the leading causes of medication error. The management of this problem has included hiring sufficient personnel and maintaining a calming ambience in the workplace. The personnel use the input of pharmacists and other medical practitioners to identify weakness in the work process. This enables facilities to streamline service delivery systems. Another method has been the increased use of technology to reduce human error. Technology adopted includes the use of online systems to key in prescriptions. This method also allows monitoring of the prescription system by other relevant personnel who can identify and prevent mistakes. The use of bedside bar coding to administer drugs is another preventing measure that has increased efficiency in monitoring the accuracy of medication given. Automated pharmacy or medical record-based triggers have been useful in monitoring adverse drug events caused by many high-alert drugs (ASHRM, 2011). Other facilities encourage staff to keep abreast of developments in medical safety via industry publications. This helps them to keep up their safety standards and prevent error by working on hitherto unforeseen weaknesses. It has also helped in the creation of a safety conscious culture adhered to by all hospital workers. Another key focus has been on the creation of blame free environments. A non-punitive approach increases the chances of detecting and remedying errors as personnel do not have fear of reprisals if they report those (Lippincott Lippincott, 2008). Incentives to personnel who report errors have also encouraged the practice. Improving communication channels between personnel has been another common principal focus. A good communication system prevents misunderstandings and creates a pleasant working environment. Errors in medication usually occur because of miscommunication or miscalculations (Lippincott Lippincott, 2008). The education of staff on relevant vocabulary and using a protocol for orders given verbally has improved significantly patient safety. Encouraging an intimidation free environment has also improved communication between nurses, doctors, and pharmacists. Compare results to the process developed at this agency Most processes adopted by other facilities are similar to those recommended by the agency. This includes the streamlined work processes, use of technology to improve service delivery and the involvement of personnel in safety related decision-making. Other strategies differ. The agency used these to improve the clinic’s service quality. These include the creation of blames free environments. The constant monitoring policy of the agency is likely to put employees on their guard. Creating a culture free of the fear of reprisals increases the chances of error detection and employees taking personal responsibility. Another method that the clinic can adopt is the monitoring of high-risk patients, as opposed to just monitoring the use of high-risk drugs. Conclusions and recommendations Medication errors are a serious risk to both patients and hospitals. They have a serous emotional and financial costs associated with them hence the dedicated efforts to prevent them and if possible attain zero medical errors. Hospitals are on the right track in combating systems errors â€Å"though† there is room for improvement. Education of the personnel the principles of error reduction such as standardization, restricted access, simplification of processes, automation, better information management, dissemination, and fail safes have all helped improved the over all safety of medication in the country. The support of the public is also an important aspect as their support rather than criticism encourages change. The inclusion of risk management in the strategy planning of hospitals will increase the successful implementation of control measures. A culture of knowledge sharing regarding safety measures encourages health practitioners countrywide to take proactive steps regarding patient safety. An acknowledgement of reported errors occurs to allow implementation of action points. These positive measures will further encourage error reporting. References American Society for Healthcare risk Management-ASHRM (2011). Risk management Handbook for Health care Organizations. Edited by Roberta Carroll. Hoboken, NJ: John Wiley Sons. Lippincott, W. Lippincott W. (2008). Lippincott’s Nursing Procedures. Philadelphia, Pa; London: Lippincott Williams Wilkins. Marshall, E. (2011). Transformational Leadership in Nursing: from Expert Clinician to Influential Leader. New York, NY: Springer. Sullivan, E. J. Decker, P.J. (2005) Effective leadership and management in nursing. Upper Saddle River, NJ: Pearson/ Prentice Hall. The Quality Patient Safety Institute of Cleveland Clinic Hospital. (2012). About the Quality Patient Safety Institute. Retrieved from http://my.clevelandclinic.org/about-cleveland-clinic/quality-patient-safety/about-quality-safety-institute.aspx