The Problem is Medication Reconciliation - Research Paper Example

NURSING Introduction The problem is medication reconciliation and mistakes made in healthcare facilities. If someone is on one drug, they may needto take another drug that has negative side effects only when mixed with the first. And the healthcare professional must know this and be able to report it, which may be a problem for some who are ethically compromised. Making sure one has the right patient and is not giving drugs to the wrong patient is a reasonable expectation of any healthcare setting. “Human factor researchers have demonstrated that confirmation bias causes practitioners to misperceive important information in their environment” (Takata et al., 2008). Unfortunately there is still a lot of human error in the healthcare setting and it is difficult for practitioners in an unsafe medical environment (lack of computer coding systems for medication-to-patient) to reduce these areas because they may not be aware. Prevention of medication mistakes Although the process of medication reconciliation appears relatively simple, it has been difficult to organize and implement systems that ensure that reconciliation happens in a reliable manner. One author shows an error due to problems in the underlying processes of care: “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” (Young, 2008). This particular perspective tends to contradict the initial assumption that mortality rates in cases of medication mistakes were relatively low when compared to other medical mistakes, but this is a matter of individuation. In the case examples, none of the results were fatal, but one was a root cause analysis event, which means that it was considered a sentinel event according to the JACHO. It is important to look at how this is also a problem that has interstices with home care environments. “Inconsistencies between patients’ admission orders and home medication regimens may occur. The JCAHO recognizes that medication safety is compromised when these discrepancies occur and requires hospitals to develop a process of obtaining histories” (Lessard et al., 2006). Hospitals can also help staff recognize the problem by putting up side-effect and drug combination charts. Education is also important, because if a person does not receive an adequate education, they are not going to be able to apply knowledge. This is especially important to point out when there are issues of life and death at stake. In terms of analysis of this issue, there are many things that hospitals can do to reduce the likelihood of medication mistakes by staff members whether they are physicians, nurses, or other healthcare professionals. First of all as mentioned 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. Also as mentioned there is the technique of color coding or bar coding medications and patients, to separate them from each other and to make the medications match being the predominant issue here. These are systems which have advanced far beyond traditional color coding and gone to a bar code system which is registered in a networked computing environment system. “All meds have a bar code on them, and the patient ID band also has one," Sublett says. "We have an online system, and when a nurse pulls up the screen, it highlights the meds to give” (Bar, 2005). Human error seems to be ultimately a variable that cannot be left out of any equation, in many cases even due to administrative oversight. It is the recommendation of the current report that hosptials deploy systems of checking on medication procedures using the latest technology to bar-code medications and patients. It is also the recommendation of the current report that ethical relativism implies that if one standard of deviant ethical behavior is followed by a nurse or a future nurse, this does not necessarily mean that this will result inevitably in medication errors occuring, or necessarily the progression of the indiviudal to a stage at which they are even in a situation in which this may be an issue. Overall it is the recommendation of the curent report that hospitals institute technological systems to help reduce medication errors, but also understand that on the human level errors are inevitable, and it is often how these errors are handled by the individual that matters at this point, rather than the prevention measures. There is the counter-argument that “Computer systems designed to prevent medication errors in hospitals can actually contribute to mistakes, but the severity of the errors is significantly less than in healthcare settings without IT” (Kramer et al., 2007). It is therefore also recommended that these errors be studied further to trace them back to the source so that a more effective implementation can be used. In one study, contradicting the results presented above, “But 1.7% of the 192,477 reported errors did require lifesaving intervention and resulted in permanent harm or death. Considering that there are more than 32 million hospitalizations each year in the U.S., serious harm from drug errors clearly is a major safety concern” (Takata et al., 2008). Agreement must be found in the extant literature, in order to effectively implement programmatic directions to address the challenge of the future. Conclusion The problem of making medication mistakes in hospitals has been a recurrent one throughout history. Various saftey schemes have been manufactured and followed but still medical errors are common. Basically there are medical errors in dosage, timing, cross-drug allergies and side effects, and type of medication (getting the right drugs to the right patient). Computers are a large part of the issue today rather than historical practices of patient bracelet ID matching systems. Computer systems arguably could reduce side effects by screening patients to weed out drug interactions that could increase side effects. Removing the general danger of side effects however is a rather too broad topic. “Computer systems designed to prevent medication errors in hospitals can actually contribute to mistakes, but the severity of the errors is significantly less than in healthcare settings without IT, according to a study by U.S. Pharmacopeia (USP), Rockville, Md. As more hospitals have implemented automated systems for administering drugs, the number of errors associated with them has risen” (Kramer et al., 2007)). It is therefore also recommended that these errors be studied further to trace them back to the source so that a more effective implementation can be used. Although it may not be possible to completely reduce human error in the nursing enviroment, it behooves healthcare institutions to do everything humanly possilbe to institute systems of checks and balances, to ensure patient safety. REFERENCE Kramer, J, Hoptkins P, Rosendale J et al. (2007). Implementation of an electronic system for medication reconciliation. American Journal of Health System Pharmacy Lessard, S., DeYoung, B and Vazzana, N (2006). Medication discrepancies affecting senior patients at admission. American Journal of Health System Pharmacy. Nester, T and Hale, L (2002). Effectiveness of a pharmacist acquired medication history in patient safety. American Journal of Health System Pharmacy. Takata, G, C Taketomo, and S Waite (2008). Characteristics of medication errors. Clinical Report. Young, B (2008). Medication reconciliation matters. Medsurg Nursing. Read More