Medication Error - Complying with the Venue Policies and Professional Standards - Case Study Example

Name Communication Event Analysis: Medication Error Course Date Communication Event Analysis: Medication Error Introduction Effective and efficient communication is important in reporting of healthcare errors and it involves verbal, written or any form of communication as well as recording of near miss that basically entails some form of reporting system. Communication aspect of medication errors also includes disclosure which entails communication of medication errors to patients and their families. Healthcare providers should understand the procedures of reporting medication errors that encompass informal and formal reporting methods. Informal communication assists in enhancing trust and confidence and both formal and informal methods communication are supposed to be part of event reporting system (Sage 2014, Pg 30). This report focuses of analyzing a medication error event that took place during professional placement experience. The analysis consists of description of the event, analysis of the communication processes, along with evaluation of the degree to which the communication processes complied with institutional policies and professional standards. Description of the Event The medication error involved a dosage error by a nurse who was handling a patient who came back from the post-anesthesia department with low respiratory rate, low pulse rate and low blood pressure as well. Doctor’s order was that the patient was to be administered with Narcan in doses of 0.2 mg intravenously in case the respiratory rate of the patient dropped below 10. When the nurse assessed the patient’s vital signs, the respiratory rate was 8, pulse rate 55 while blood pressure was 88/60 and thus as per the doctor’s order, the nurse prepared an IV Narcan dose to stabilize the patient’s vital signs. After the nurse administered the medication, he began charting the administered medications and immediately noticed he had administered the patient with 2 mg rather than the prescribed dosage of 0.2 mg, 10 times the recommended IV dose. The nurse immediately reported the error to the charge nurse and quickly went back to the patient. He then took the patient’s vital signs again and established that the vital signs were back to normal rates. The nurse called the attending doctor and reported the error as well as the patient’s state. The nurse then filled an incident report as per the hospital’s policy and left for home. After one week, the nurse wrote a report regarding the event that was sent to the risk management department in the hospital. Analysis of the Communication Processes According to Zane (2010, pg 8) healthcare error communication strategies involve reporting errors and disclosure. Communication process of reporting errors include verbal and written communication methods within the institution, for instance to the nurse in charge, fellow healthcare providers, the physicians, risk quality and safety officers, management and institutional board of trustees as well. Reporting also involves the medication error being reported to the relevant external institutions such as state, professional organizations and such. The communication aspect of disclosure involves communicating and disclosing the event to the patient and families as well (Zane 2010, Pg 8). During this event, the nurse reported the event to the nurse in charge as well as to the other concerned physician. This was done through verbal communication to the nurse in charge and the nurse communicated the event to the concerned physician through a telephone call. Communicating the incident to the nurse in charge was important because the nurse in charge was informed of the event which can allow her to take the necessary action to manage the patient’s situation in case the dosage error affected the patient adversely (Sage 2014, Pg 42). The nurse utilized the best communication strategy when reporting the incident to the nurse in charge and the physician as well because she informed them immediately. Immediate reporting of the medication error is very important because the supervisors and doctors get a chance to ask questions and enquire about the event when the event is still fresh in the mind of the reporter. As Steeb (2013, Pg 16) puts it, an oral report to the supervisor can be more effective communication strategy than a hurriedly written report and thus it was very appropriate that the nurse reported the event to the nurse in charge verbally. The nurse also filled an incident report which was used in communicating the incident to both his supervisor and the physician but also to the management as well. The incident report promptly and comprehensively communicates the entire event to the concerned parties. For instance, filling the incident report during this event the nurse was able to communicate the medication error, how it occurred to his supervisor, other staff members and the institutional management as well because in the long run the incident reports are forward to the appropriate managers to carry out the investigation of the event. According to Government of Western Australia (2012, Pg 5) such an error incident report is vital in communicating important information which is not only important in achieving correction or change but such incident reports also serve as effective communicational tools in healthcare organizations because they serve as an efficient management and educational tool in regard to affected healthcare providers (Government of Western Australia 2012, Pg 5). However, the nurse did not disclose the event to the patient or his family. Complying with the Venue Policies and Professional Standards The nurse complied with the hospital policy and professional standards as well by reporting the event to the nurse in charge and the physician. This is because the professional standards obligate healthcare providers to admit and report such medication errors. Similarly, the hospital’s policy requires them to report such events to their supervisors for the necessary action to be taken. The completion of the incident report by the nurse was also in accordance with the hospital’s policy because the hospital requires healthcare providers to complete the incident report whenever such an event occurs. Additionally, the nurse made the final report which he submitted to the risk management department as per the hospital’s policy in order for the risk management to carry out the necessary activities to prevent such harm from occurring again (Sage 2014, Pg 46). However, the event was not disclosed to the patient. Professional standards stipulate that patients are entitled to information regarding all aspects of their health for the patients to be able to give informed consent to treatment. This entails the patients being informed of any risk of harm allied to their treatment and also to be informed of any risk of harm (National Medicines Information Centre 2010, Pg 4). Communication regarding medication errors involves reporting and disclosing of the actual medication errors and near missies. This includes the healthcare providers offering accounts of errors and sharing with patients and significant others and it greatly assists in reducing the impact of medication errors and also prevents the probability of future errors by actually warning other healthcare providers regarding the potential risk of harm (Sage, 2014). For instance, during this event the nurse confused a2 milligrams per 1 milliliter (ml) with a when administering a 0.2 mg medication and hence reporting and disclosing this incident can help in warning and alerting other healthcare providers with the institution to avoid such an incident again. In addition, effective communication not only lowers the number of future medication errors, it also diminishes personal suffering and reduces financial costs. Disclosing a medical also benefits the patients and healthcare practitioners through providing them with instant answers regarding medication error and lowering long litigation. Disclosing medication error is an obligation even though nurses and healthcare managers and administrators are normally not comfortable with it (National Medicines Information Centre 2010, Pg 4). According to the common law, doctrine of informed consent obligates healthcare providers to disclose such a medication error to patients. According to the doctrine of informed consent, healthcare practitioners should disclose to patients any aspect that a reasonable individual in the patient’s state would need to know and this encompasses any error that might have taken place during nursing care. The duty to divulge such a medication error also emerges from the fiduciary nature of the nurse patient relationship, which obligates healthcare providers to act in good faith in regard to their patients’ best interests and this consists of informing patients when anything goes wrong during treatment. Therefore, under common law the nurse was obligated to disclose the dosage error to the patient (National Medicines Information Centre 2010, Pg 6). Still, the hospital policy requires healthcare providers to inform the patient about such incidents. According to the hospital’s policy, when a patient sustains harm when under care of a healthcare provider, the healthcare provider should make sure that harm is revealed to the patient or to his/her substitute decision maker. The nurse never informed the patient regarding the dosage error and hence the nurse did not comply with the institution’s policy. Such disclosure is important because it assists in fostering good communication and openness which is fundamental in sustaining trust in the patient healthcare practitioner relationship Department of Health and Children 2010, Pg 5). From the analysis, there was open communication regarding medication error event. Apart from the fact the nurse did not disclose the event to the patient; the nurse used the required communication strategies to report the event. Such open communication when reporting medication error ensures effective safety in medication management which is a vital element of professional practice for registered nurses; an open communication is the key to safety in medication management (Department of Health and Children 2010, Pg 5). Bibliography Department of Health and Children, 2010, Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance, Dublin: The Stationery Office Government of Western Australia, 2012, Open disclosure policy: Communication and Disclosure requirements for health professionals working in Australia, Government of Western Australia. National Medicines Information Centre, 2010, Medication Errors, An Bord Altranais News, Autumn, 20 (3): 10-11. Sage, W., 2014, How Policy Makers Can Smooth the Way for Communication-And- Resolution Programs, Health Aff, 33 (1): 1 11-19. Doi: 10.1377/hlthaff.2013.0930. Steeb, D., 2013, Improving Care Transitions: Optimizing Medication Reconciliation, New York: American Pharmacists Association. Read More