Medication Errors in Emegency Department - Research Proposal Example

Oman Specialized Nursing Institute Research Methodology I Course MEDICATION ERRORS IN EMEGENCY DEPARTMENT Done by: Hamed Mohammed AL alawi Student # EN008 MEDICATION ERRORS IN EMEGENCY DEPARTMENT SECTION 1: BACKGROUND INFORMATION Introduction The meaning of the statement, “medication error” is explained by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) (2015). The Institute of Medicine (2014), medication error is defined as any preventable activity causing inappropriateness in medication application, and use. Alternatively, medication error can also be referred to as the patient harm influenced or caused by a health care expertise, patient or a consumer during the medication period. The events factoring to the medication error in emergency department are associated with professional practice, the health care facilities and products, measures and systems. Therefore, the medical errors in emergency department mostly occurs during procedural and systems in medication mannerism such as, order of communication, medical prescription, nomenclature, administration of the drug, as well as education, monitoring and usage. Medication errors are much common in emergency departments in the whole world. The problem is as a result of various potential factors that promote a conducive and ideal atmosphere for health thrive of medication errors. Medication errors can be prevented; however, it’s very dreadful and catastrophic when they take place. Research question The research questions guiding the research proposal are: 1. what are the causes of medication errors in the emergency department.2.The possible mitigation programs for such medical errors. The Purpose The purpose of the study is to examine causes and to identify programs to reduce medication errors in emergency department. LITERATURE REVIEW Medication Errors There are no data regarding medication management and medication errors in Oman Country, hence this triggered me to take the initiative of giving a proposal to educate the people on the major causes and mitigation of medical errors in emergency department. Methods such as: observation of medication errors, interviewing participants regarding their thinking processes during medication management, and retrospective review of incident reports and questionnaires about medication errors (Antonow, et al., 2010). This section discusses the literature review of those studies related to frequency, types and origins of medicine errors in current research. Frequency of Medication Errors For every drug administered to a patient in emergency department, there is the possibility of an error (Nichols, et al., 2011). A review of the literature provides a starting point for further investigation of medication errors despite the fact that each institution may have a unique pattern of error. Reports of medication error rates use a variety of denominators (per admissions; per patient days; and errors per number of medication orders [IOM, 2007]). Nebeker, et al., (2015) examined medication errors at a veterans’ hospital and reported 70% adverse drug events (ADE) per 1000 patient days. An error rate of 6.5% ADEs per 100 admissions was reported from medical surgical units in two tertiary care centers (Leape et al., 2015). Lesar (2012) recorded 12.3% errors per 1000 admissions. A rate of 40% errors per 1000 admissions was recorded in a major tertiary care center (Winterstein et al., 2014). One hospital study estimated medication errors to be as high as 1.9% errors per patient per day (Fontan, et al., 2013). Emergency Department: Types and Causes of Medication Errors Medication errors are of significant concern in the care of patients in critical situations. The medical errors concerns can occur during any of the five stages of the medication process of the patients in emergency conditions: prescribing, transcribing, dispensing, administering and monitoring (IOM, 2000). As an example of reported rates, errors associated with adverse drug events (ADEs) in one study that occur in the following stages: 61% ordering, 25% monitoring, 13% administration, 1% dispensing (Nebeker et al., 2015). Several authors describe faulty emergency machine system design as a primary source of medication errors (Cullen, et al., 2010). Often the lack of access to important patient and medication information results in errors (Winterstein, et al., 2014). Specifically, dissemination of knowledge about medications and their dosages, as well as patient laboratory test results and drug history, are necessary for improved emergency patient safety. Prescribing errors by physicians were detected in several emergency rooms. The range of prescribing errors varied from 56% to 75% of all errors (Cullen, Bates, & Leape, 2010). The errors reflected the wrong medication attendance ordered emergency clinicians for patients along with inappropriate dosing (Cullen, Bates, & Leape, 2010). Many of the errors caused by prescription fault of the emergency physicians in the department are as a result of inadequate knowledge about the medication being ordered. Therefore a well established medication protocol should be observed to reduce incidences of error. Sometime due to the critical condition of the patient in the emergency department, the physicians mostly rush to treating the patient without considering the previous laboratory test values (Nichols, et al., 2011). At the preparation and dispensing stage (pharmacist’s responsibility) errors occurred in 2.9% per 1000 admissions (Winterstein et al., 2014). Only one percent of errors were due to pharmacist’s mistakes in a study by Nebeker, et al., (2015). Fanikos, et al., 2013) identified 27 out of 361 (4.9%) dispensing errors in their study of medication errors in cardiac/heart related problem patients. Nichols, et al., 2011), describes that surgical errors (Doctor’s responsibility) occurred in 5.8 per 1000 admissions (Winterstein, et al., 2014). Nurses in an intensive care unit were observed during 2,009 instances of medication administration events with a recorded 132 instances of medication errors (6.6%) (Tissot et al., 2009). Medication errors in an intensive care unit were due to deficiencies in staff training (Tissot et al., 2009). Specific types of errors related to administration included medications given at the wrong time, wrong dose (high and low), missed doses, wrong administration technique, and not identifying patient allergies (Bohomol, et al., 2011). Lack of knowledge of the drug and failure to scan the patient’s identification band in emergency department results to medication errors (Mayo and Duncan, 2014). Medications errors in the administration stage were related to performance deficits (delays or miscalculations) and inappropriate drug routes (Winterstein, et al., 2014). Mitigation Factors Influencing Medical Errors in ED The following discussion identifies common patient and ED factors contributing to medical errors and the management of such medication errors. Age: patients aged 65 years and above are at a higher risk for medication errors in critical conditions (Gallagher, et al., 2010). At this old age, the patient’s white cells are weak and fragile. As a results patients’ mortality rates increased in older individuals experiencing adverse drug events (Classen, et al., 2007). Patient acuity: the patient’s acuity level can affect the complexity of care (Fijn, et al., 2012). As patient acuity increases so does the complexity of the care and the number of medications that are needed to support the stability of the patient (Scott, et al., 2013). A higher risk of patient mortality has been identified with higher acuity and adverse drug events (Classen, et al., 2007). Furthermore, high acuity patients may affect nurses’ workloads by decreasing the time in which to focus on the care of other patients, thus increasing the risk of not recognizing a medication error (Balas, et al., 2014). Medical diagnosis: the patient’s medical diagnosis contributes to the complexity of care (Gallagher, et al., 2010). Few studies have reported the medical diagnoses of patients experiencing medication errors. Two studies focused exclusively on cardiac patients and reported a medication error rate of 1.9 events for every one hundred admissions (Fanikos, et al., 2013) and 16% of Acute Coronary Syndrome patients experienced medical errors with a majority of them related to medication errors (Rothschild et al., 2013). Patients with diseases of the digestive system were found to have significant medication errors in several studies (Nebeker, et al., 2015). The selection of medical diagnoses for this study is representative of conditions that may use two of the common drug categories most frequently seen in medication errors: narcotic analgesics and antibiotics (Lehne, 2014). Drug categories: knowing the drug categories that are at highest risk for errors can alert nurses, physicians, and pharmacists to potential problems during medication management. A review of Coombes, et al., (2008) research findings reflected a unique pattern of error for each institution studied. Narcotic analgesics and/or antibiotics were found to be listed in one of the top three drug categories reported as causing medication errors in emergency department (Calabrese, et al., 2011). Researchers did not offer an explanation as to why these two drug categories frequently resulted in medication errors. Route and dose: drugs must be administered via the route that is appropriate for the formulation and concentration of each medication (Lehne, 2014). The intravenous route offers no barriers to absorption which is immediate and complete. Intravenous medication is dangerous since toxicity can occur if medication is given too rapidly even if the dose is appropriate for the route (Lehne, 2014). Oral administration route is considered safer than the intravenous route. Doses of particular drugs may vary in amount when given intravenously versus orally (Lehne, 2014). Nurse’s familiarity with prescriber Communication with physicians in medication emergency department is essential to prevent errors (Eisenhauer, et al., 2007). Nurses have an easier time of interrupting an error if a physician is known to them (Henneman, et al., 2006). Nurses will ideally have knowledge of the physician’s protocols 29 for patient care and have access to recent lab work and test results. Nurses are then prepared to question orders and communicate concerns to the prescriber (Wakefield et al., 2010). Time of day: Determining the time of day when the majority of the errors occur assists nurses in developing strategies to prevent errors. Studies have shown that the earlier portion of the day shift (7 AM – 11 AM) has the highest rate of medication errors with the idea that this is the prime time for medication operations and administration in ED (Fahimi et al., 2011). Moreover, there is an increase in the rate of medication errors during periods of shift changes and the first two days of the patient’s admission to the emergency department (Fanikos et al., 2013). Additional concerns related to time of day identified that as shift lengthened for nurses (greater than 12 hours) the number of medication errors increased (Rogers, et al., 2014). Level of education: Competent and well educated clinicians should be allowed to attend the critical patients especially in ICUs to avoid some of the medical errors in emergency department. Clinicians with professional competency have tremendously reduced the medication errors in ED (Hall, et al., 2014). Chang and Mark (2009) found that as the percentage of baccalaureate prepared nurses increased on a randomly selected number of nursing units the number of severe medication errors decreased. The Theoretical Framework Rasmussen’s (1997) Theory is a Risk Management Framework that is applied to determine the sophisticated matters that leads to infusion and medical errors. The theory was developed in 1997 by A Rasmussen’s. The theory of Rasmussen is a continuation or an extension of Leveson’s Systems-Theory Accident Model. The Rasmussen’s theory therefore, is used especially in modeling errors behavior in complex healthcares. The components of Rasmussen’s Theory include; 1. Skill-based section which involves the implementation of failure, 2. Rule-based section that deals with the error during rule application. 3. Knowledge-based criterion, the section exhibit errors resulting from the biasness and the mindset leading to instructs incorrect solution for a given situation. According to this theoretical framework, the predictability of the errors is connected to the experience, complexity and the familiarity with the type of the task a nurse is delegated. The applicability of the framework to the proposal research is diverse. The Rasmussen’s Risk Management Framework was used to scrutinize the information derived from the literature review, database review and observations in clinical peripherals. During the application, the factors throughout the whole system are considered and the information was examined in respect to the cause-consequence connectivity with the factors and the levels of the system. In support to the first objective, Rasmussen’s Skill-Rule-Knowledge was exercised to evaluate if the human performance had produced a failure to use the correct and required skills, rules or knowledge. Conclusion Data reviewed from healthcare facilities reveal medication errors as a common occurrence, with each institution having a unique pattern of error. Research demonstrates that the highest percentages of medication errors are associated with incorrect physician prescriptions. Physicians need to improve their knowledge of medications available for patient therapeutics; however, this does not exempt nurses from their responsibility for patient safety. Although medication prescribing falls under the control of physicians, nurses are fully responsible for administering the correct types and dosages of medications. Safe medication administration involves careful review of physicians’ orders, accurate knowledge of the medications, and the courage to question potentially inaccurate and inappropriate medication prescription orders (Mayo & Duncan, 2014). There are times of the day when nursing units can be very busy places which are prime times for medication errors to occur. This heightened activity can result in errors in medication management. In recent years with the onset of computers being used for medication management, there has been a great deal of research supporting the safety of Computer Physician Order Entry (CPOE). Although this seems to have a positive effect on reducing medication errors there is a lost opportunity for communication between healthcare professionals (nurses, physicians and pharmacists). Nurses’ Characteristics Influencing Medication Management Nurses bring professional (education and experience) characteristics to the bedside as care is given to patients. REFERENCE Antonow, J., Smith, A., & Silver, M., 2010. Medication error reporting: A survey of nursing staff. Journal of Nursing Care Quality, 15(1), 42-48. Balas, M., Scott, L., & Rogers, A., 2014.The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research, 17, 224-230. Bohomol, E., Ramos, L., & D'Innocenzo, M., 2011. Medication errors in an intensive care unit. 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