Analysis of Medication Errors - Research Paper Example

Analysis of Medication Errors Situation Medication mistakes or errors is a large ethical and legal area in nursing specifically, as well as healthcare generally. Although medication errors result in relatively low mortality rates compared to some other medical and healthcare environment mistakes, it is still an issue that has serious side effects, and it is obvious that hospitals, clinics, and other healthcare delivery locations must have systems in place to combat mistakes in medication, including clearly visible medication charts showing cross side-effects in public areas, proper education of staff about what to do when there has been a medication error, and other methods such as color-coding medications and establishing bar code systems. There are many things that organizations can do to reduce errors due to problems in the underlying processes of care, so that they can address these problems on the systemic level. This is a complicated issue because there is always going to be the element of systemic error in the healthcare environment, and no technologically sophisticated program really seems to have solved and totally eliminated the problem of persistent medical error. Therefore, it is important to address the issue because of its prevalence and its persistence. “A new report from the U.S. Pharmacopeia (USP) reveals that hospital medication errors may be on the increase despite efforts to combat the problem. The study also found that hospitalized patients over age 65 are twice as likely to be harmed by an error, accounting for half of all error-related deaths. The report is based on an analysis of medication errors submitted to the USP's tracking system” (Dale, 2003). This particular perspective tends to contradict the initial assumption that mortality rates in cases of medication mistakes are relatively low when compared to other medical mistakes, but this is a matter of individuation. In case examples, even if the results are not fatal, there is still cause for a root cause analysis event, which means that these errors are considered a sentinel event. Issues and values Issues of discrimination may come up as being linked to medication errors, especially in malpractice suits which also seek civil damages. As it is, in procedural errors, it is difficult to tell whether any of the errors on the scenarios are due to discrimination in this environment. “According to numerous studies, ethnic and racial minorities often receive lower quality health care than Caucasian patients, even when such factors as medical conditions, insurance and economic status are equivalent. Disparities range across the full spectrum of health services -- from who gets prenatal care to the quality of care received at the end of life” (Programs, 2007). This also means that these population are more likely to fall victim to medication errors. Reducing discrimination in treatment and equalizing care for all patients regardless of race, socioeconomic status and age are among some of the things that organizations can do to reduce errors due to problems in the underlying processes of care. In further analysis of this issue is the social climate of the workplace and its relation to nurses and physicians, including how they are trained in this climate to act when there has been a medical error. This often brings up complicated issues for healthcare workers such as whistle-blowing and ethical relativism. In terms of analysis it seems that whistle-blowing is warranted in some cases, where the potential harm to society of having someone incompetent working as an administrator nurse or doctor, is a real issue, and the person should be ratted out and fired. Also some workers if they perceive the medical error to be a factor will just look over it and never blow the whistle on everyone. Impact on clients Obviously, the client is the point of impact of a medication mistake made by a nurse or physician. Clients also want to know that healthcare staff are doing everything they can to prevent errors, which makes it disturbing that, “Another finding of concern in the study is that (healthcare professionals) may not report a medical error if they think it's unimportant, which contradicts the contention that reporting near misses and actual errors helps prevent future serious errors. The researchers noted that various professional and work-group cultures may diminish systems improvement” (Dale, 2003). Impact on clients also revolves around professional competence.Generally, competence can be measured by an individual’s ability to work inside of their known boundaries and not try to overstep or exceed them. One can be the judge of one’s own competence. Professional competency can also, at times, be an effective evaluation of competence in the nursing setting. Competent individuals are dynamically involved in providing helpful solutions to their clients, and are always in a state of learning from their ever-changing environment. In this way, true professionals never stop developing their skills to rest on a plateau. If a patient is ignorant about how to take their medication, when to take it, and other issues, they are not going to be able to get better. The nurse or other healthcare professional must try to put safeguards into effect which guarantee the patient’s safety in a more holistic way. “The U.S. Food and Drug Administration (FDA) believes that many of these medication-related risks are manageable if parties committed to the safe use of medications work together. Potential partners in Safe Use include: Federal agencies Healthcare professionals and professional societies” (Treatment, 2007). Most mistakes are preventable. Importance to nursing In terms of analysis of this issue, there are many things that nurses in healthcare facilities can do to reduce the likelihood of medication mistakes by staff members whether they are physicians, fellow nurses, or other healthcare professionals. First of all the healthcare provider can provide education on a continuous basis to its employees. Many people after they get out of nursing school don’t remember all of the complicated drug interactions and medication interactions which are constantly changing as well. So displaying these in an easy to read chart format predominantly in the hospital can keep the information easily at hand to reduce errors. This represents a process oriented model to address problems in the underlying processes of care, in which the organization can take responsibility and make proactive choices, in order to educate its professionals in the correct conduct and reduce errors. In one study, “Results demonstrated that perceived suitable safety procedures and frequent and clear information flow reduced treatment errors only when managers practiced safety and through their influence on the level of priority given to safety within the unit. Implications for safety climate theory and for reducing the occurrence of treatment errors by safety interventions are discussed” (Treatment, 2007). In other words, positive organizational communication is the key to reducing this sort of error.As it is, in some procedural errors, as mentioned, it is difficult to tell whether any of the errors on scenarios are due to discrimination in this environment. If a client feels that they have gotten a medication mistake because of poor treatment based on their race, ethnicity, or socio economic status, there is likely going to be more of a challenging legal situation for the healthcare facility, due to the interstices of civil law. Recommended approach Even though systemic error is persistent or appears to be, and short of totally removing organizational administrative control from the healthcare environment it is not likely that an error due to problems in the underlying processes of care is going to be stomped out completely, it is still important to look at prevention programs to see how, if they cannot be eliminated, medical mistakes can be reduced. “The IOM report, To Err is Human, also recommended immediate, proven steps that could be taken to reduce medication errors. As a result, many hospitals and other health care facilities have been engaged in efforts to reduce mistakes in drug prescribing and dispensing. They include computerized drug ordering systems, bar coding patients and their medications and having clinical pharmacists oversee drug prescribing” (Dale, 2003). These are not presented therefore as complete solutions to the problem, but approaches towards reducing medication mistakes which can work on a holistic level for healthcare professionals. Nurses can also act as advocates at their respective healthcare facilities, to ensure that the most modern equipment is being used, and that medications are charted and coded appropriately. However, no one is perfect, and as long as doctors and nurses continue to be human beings, human error in the healthcare field is likely going to continue. New interstices with technology, however, may cut down on these errors, such as a “computerized medication box stores prescription medications, emits an audible alert to the patient when medications are scheduled to be taken, and releases them onto a delivery tray when activated by the patient at the appropriate time. It uses a Web-based application” (Avoid, 2010).   REFERENCE Dale, D. (2003). Hospital medication errors may be on the rise - Rx News Healthfacts. Avoid medication mistakes (2010). http://www.fda.gov/forconsumers/consumerupdates/ucm096403.htm Medication errors (1994).Agency for Health Research and Quality. http://www.asq.org/qic/display-item/index.pl?item=19947 Programs to reduce healthcare disparities (2007).NCQA. http://web.ncqa.org/tabid/595/Default.aspx Treatment errors in healthcare (2007). http://portal.acm.org/citation.cfm?id=1075351 Read More