Reflection on Drugs Errors - Case Study Example

? Reflection on Drug Errors Reflection on Drug Errors Introduction Nursing is a vital component in providing health care services to the patients. Thus, nurses should be fully equipped with sufficient theoretical knowledge and practical skills to be able to render appropriate nursing care. Dispensing and administration of medications are integral in nursing care. I was given the opportunity to observe medication errors during my transition period and came to the conclusion that they are a common occurrence even at pharmacies. My first hand experience in medication errors during the transition period and the scientific studies on the topic broadened my perspective on the causes of drug errors and the recommendations to lessen if not totally eradicate them. The observation was made six days a week and at different times of the day. Several pharmacies were visited. I tried to remain an unnoticed observer, and to do this, I had to purchase some medications in order to merge with the other customers. As a passive observer, I did not interfere in the interaction of the pharmacist and customer if I noticed a drug error. Drugs, which are meant to treat a patient, may have an adverse effect if administered not according to the prescribed dosage. Error in drug administration can happen in any setting, in the clinic, hospital or other health institutions. But drug error can also occur while prescribing, ordering or dispensing of drugs by the pharmacists. Since it has become a serious health concern, studies have been conducted by scholars from the different health care sectors. Adverse drug events include the following drug-related interventions: error during prescription, dispensation error, and administration of medication (Bates, Cullen, Laird et al. 1995, cited in Flynn n.d.). Vadney (2003) said that around 11 to 14 percent of medication errors happen in the pharmacy. Nurses have the responsibility of administering medications, and therefore, they must “meet the legal standard, . . . knowledgeable about the medications given, careful in administration, and alert to potential problems that may result in errors” (Malseed 1990, p. 45). Many of the medication errors committed by nurses include their inability to yield follow institutional policies which are designed to protect both nurses and patients (Malseed 1990). Nurses should take extra precaution in drug administration so that patient safety is ensured (Malseed 1990). From such experience, I learned that nurses, being the last in the line before the drugs are given to the patients, must exert a high level of precaution before administering the drugs to the patient. This can be attained by taking time to verify the order, prescription and dosage. Even if the medication has passed another level of verification before reaching me, I must still undertake on my own to see if what I will be giving to the patient is the correct medication. Literature Review Medication error is a “preventable event that may cause or lead to inappropriate medication use or harm to a patient” (FDA 101 2009, p. 1). Medication errors happen regularly although they can be prevented or avoided (Brennan et al. 1991; Bates et al. 1995, cited in Cina et al. 2006). Medication error is defined by the National Coordinating Council for Medication Error and Prevention as “any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer” (Flynn n.d.). The events contemplated are varied and associated with practice, procedure, system and the product itself. They also include the following: labeling of the product, packaging, compounding, nomenclature, prescribing, communicating the order, distribution, dispensing, administering to patient, monitoring, education, and use by the patient (Flynn n.d.). Medication error on the aspect of administration is defined as a deviation from the written order of the prescriber, or upon entry of the item into the computer by the prescriber (Flynn & Barker 1999, cited by Flynn n.d.). The error committed by the prescriber when ordering medication is generally referred to as prescribing error (Flynn n.d.). According to Chambers (2007), medication errors may result from the following situations: a) utilizing wrong procedure for diagnosis or erroneous sequencing of agents, b) using wrong patient parameters for determining dosage (e.g. height, weight, body surface area), c) failure to change the dosage (when there is organ dysfunction, or there are changes in response or toxicity), d) exceeding the highest cumulative or individual doses, e) failure to order related therapy (e.g. antibiotics, hydration), f) dosage, duration or frequency is not clear, and g) wrong transcription, not readable handwriting, and drug name confusion due to similarity. The Food and Drug Administration (FDA) said that since 2000, more than 95,000 incidents of medication errors has been voluntarily reported to it (FDA 101 2009). Medication errors mentioned in the report included several causes, such as: poor handwriting (resulting to miscommunication), similarity in names (that leads to confusion), low quality packaging design, and confusion with the different dosage units (FDA 101 2009). The risk in the commission of drug error can be reduced by engaging in the following remedies: a) conducting a review on drug names to lessen confusion, b) collaborating with pharmaceutical companies to discuss improvements in labeling and packaging, c) making an intensive analysis of the reported drug errors reports, d) use of bar codes on specific drugs, f) formulating guidelines for pharmaceutical companies, and g) educating the public (FDA 101 2009). According to Flynn (n.d.), drug errors committed in pharmacies are really higher than what has been observed or reported, and thus, pharmacists have been studying this area for more than four decades. In the 1962 study conducted on error detection, data from incident and voluntary reports recorded 36 errors in one year, while in direct observation of nurses, the two-week data gathered which were extrapolated for a year yielded 51,200 errors (Barker & McConnell 1962, cited in Flynn n.d.). In order to facilitate research grounded on drug errors, specific errors were identified such as: a) unordered or unauthorized drug error (administering a dose of medicine not ordered for patient, also called wrong drug error), b) extra dose error (excess dose than that ordered by doctor, e.g. drug is discontinued, administering an expired order, drug is put on hold), c) omission error (failure of patient to receive dose ordered, no attempt made to administer dose, reason for omission must be given such as policy or surgical requirement), and d) wrong dose error (dose given is not according to preformed dosage units or 17 percent higher or lower that prescribed dosage) (Flynn n.d.). Other researchers narrowed down the meaning of wrong dose error to that of injectable doses which the nurse measured 10 percent more than the dose ordered (Barker & McConnell 1962; Barker, Kimbrough & Heller 1966; Schnell 1976; Barker, Heller, Brennan et al. 1964; Jozefczyk, Schneider & Pathak 1986, cited in Flynn n.d.). This type of error is applied for medications wherein the doctor specifically mentioned the quantity (in inches of ointment, e.g. topical solutions, ointments and similar applications) (Flynn n.d.). There is also the wrong route errors which refers to the administration of medication in another route (e.g. intramuscular medication is given orally, medicating the right eye instead of left eye) (Flynn n.d.). The effectiveness of medication could be determined by the route of administration (Buckton 1995). A route error can be harmful to the patient (Buckton 1995). Drugs can be absorbed through the mucous membranes, or other routes such as suppository (rectal, vaginal), lozenges (oral), powder (nasal), and tablet (buccal, sublingual) (Buckton 1995). In hospital pharmacies, dispensing drugs usually follow two steps: the technician fill the medication orders and the pharmacist verify the drugs ((Pedersen, Schneider & Scheckelhoff 2003, cited in Cina et al. 2006). In the US, hospital pharmacies dispense millions of drug doses yearly, and this could result to numerous errors even if the error rates are low (Cina et al. 2006). According to Leape (1995, cited in Cina et al. 2006), previous studies had shown that nurses were able to detect only 33 percent of fatal medication dispensing errors prior to administration. Thus, majority of the erroneously dispensed medications reach the patients (Leape 1995, cited in Cina et al. 2006). Since the persons who get hospitalised are most probably in a critical situation, such errors could cause more harm to the patient (Bates et al, cited in 1999). The reported error rates vary and the range could be within 0.0041 and 3.6 percent (Bates et al. 1995; Ness, Sullivan & Stergachis 1994; Woller 1991; Facchinetti, Campbell & Jones 1999, cited in Cina et al. 2006). In a recent study conducted by Cina et al. (2006), in the 140,755 medication doses that were subjected to observation, the accuracy of the technician filling the medication was 96.4 percent. The verification accuracy of the pharmacists was discovered to be much lower; they were not able to detect 20.9 percent of the filling errors of the technician (Cina et al. 2006). The pharmacists intercepted around 80 percent of the error of the pharmacy technicians, with 25 percent of the errors not detected being potentially harmful ADEs (Cina et al. 2006). This can translated to 45,000 annual dispensing errors, with 10,600 potentially harmful ADEs (Cina et al. 2006). The study suggested that the errors committed in relation to dispensing process are as follows: a) the repetitive action during inspection causes fatigue (Reason 1990, cited in Cina et al. 2006), b) humans are not skillful in noticing “rare events” (the rarity of the errors make it harder for pharmacists to detect), c) the workaround process provides an opportunity for the occurrence of errors (dangerous practices become normal and accepted behavior since no ill effect has resulted (Vaughn 2004, cited in Cina et al. 2006), d) confusion with similarly looking and sounding medications (research indicated that it accounts for 25 percent of medication errors) (Lambert 1997, cited in Cina et al. 2006). Checking only one tablet from the large amount of drugs dispensed by an automated machine may become a practice if no adverse events happened (Cina et al. 2006). Personal Observation During my three-week transition period, I visited some pharmacies to observe the occurrence of drug errors. I tried as much as possible to an “invisible” observer so that the pharmacists would not notice that I was observing them. In this manner, they would become conscious of what they were doing. Moreover, I also intended not to stay for several hours so that my observation would not be compromised or someone from the pharmacy would accost me. However, I visited the pharmacies several times at different periods so that I can observe as much drug errors as possible. At times, I also purchased some medications so that I can remain at the counter and observe the pharmacists and customers for a sufficient period of time. During such transition period, the drug errors I observed include miscalculation (four times) and over-dosing (five times). The customers counter-checked the items they purchased and complained to the pharmacists once they found out that they were given the wrong dosage. I noticed that drug errors occur when the pharmacists were pressured to think faster because there were many customers to attend and when distractions were present. Drug errors were also committed when the medication requires mixing a solution or when the measurement used decimal points. I also noticed that the handwriting of the doctor in the prescription is not clear enough for the pharmacists to read. And at another instance, the doctor had written a wrong prescription. The transition period has not only given me a first-hand experience on drug errors but also made me realise how the errors are commonly committed in the pharmacy. Thus, I should be more vigilant in my practise as a nurse so that I would not commit medication error or I will be able to detect one before administering drugs. Reducing Drug Errors Medication errors can endanger the patients and should be prevented (Vadney 2003). The Institute of Medicine reported in 1999 that more than 7,000 persons had died from such error every year (Vadney 2003). The costs of preventable adverse drug events in hospitalised patients are high – around $2 billion annually (Corrigan, Donaldson & Kohn, 1999, cited in Vadney 2003). Since majority of those affected by such errors are outpatients or in an ambulatory setting, the overall costs in terms of injury and death may not have been taken into account (Vadney 2003). In the studies on error reduction involving two pharmacies in a military medical group (an ambulatory clinic and a small rural hospital), it was suggested that by minimising the number of drug strengths would provide limited choices, thus, eliminating the chance of committing errors (Vadney 2003). It also recommended the following actions in order to lessen errors: adopting a color-coding scheme based on the strengths of medicines (i.e. black for single strength medication, for multiple strengths, the lowest will be coded as blue while the highest is red), changing the shelf and container labeling, reviewing the workflow process, and training the newly hired (must be accompanied by mentors until certified to work alone) (Vadney 2003). The labels and containers should be able to show the differences and strengths of the drugs through colors, varying shades or exaggerated letter designs (Schneider 2002, cited in Vadney 2003). The lower containers should have larger letters than the upper containers so that the pharmacist would not bend too much to read drug names (Vadney 2003). Medication errors can also be reduced by providing sufficient lighting inside the workstation, reducing noise and other distractions, redesigning the workstation and placement of equipment, reducing the number of choices by placing clear labels on the drugs and shelves, standardising the work process, and reviewing/revising the criteria in hiring new personnel (Vadney 2003). Redesigning the workplace though would need engineers specialising in human factors so that the placement of medications and movement of pharmacy staff would be highly efficient (Vadney 2003). This way, the available spaces in the pharmacy would be greatly utilised. Taking into consideration the human factors engineering in the design of the workplace and workspace would also improve the safety level of the patients (Vadney 2003). There should be a learning module prepared specifically for a new staff (Chambers 2007). The Alberta Cancer Board said that a learning module is a complementary learning tool to professional education (Chambers 2007). A checklist is an important tool that would serve as a reminder in high-risk industries with complex tasks. It is a recommended devise in human factors engineering so that the staff would have a reminder of the complex processes (Reason 2002, cited in Chambers 2007). Conclusion Medication error can occur in any of the stages from prescription, dispensation to administration of medicines. Commission of medication error most often involves a human element. Different health care institutions and providers consider this an important concern because it can cause more harm to the patient and even death. The Centers for Disease Control and Prevention provided an estimate of around 7,000 children aged 11 years and below being treated in emergency rooms in hospitals annually for overdose of over the counter (OTC) drugs for colds and cough (FDA 101 2009). And more than 7,000 persons had died annually for medication errors (Vadney 2003). For instance, the prescription of Tussionex to 6 six and older patients than the usual 12 hours interval resulted to breathing difficulties and other fatal consequences (FDA 101 2009). The irony of these adverse events is that these errors could have been prevented. It has been suggested that electronic dispensing of drugs would lessen human intervention and thus lessen medication errors. However, automatic dispensation of drugs has not reduced the number of errors (Barker, Felkey, Flynn & Carper 1998, cited in Flynn n.d.). Electronic prescribing though can reduce error since the doctor will directly input the medication into the computer, thus lessening intervention by the nurse or interpretation of the pharmacist when presented a handwritten prescription. There are peculiar instances in every institution or pharmacy that lead to medication errors. Thus, each setting must be studied based on its own unique condition, but taking into consideration other studies that have been implemented elsewhere. Human elements have contributed much to medication error. Therefore, these must be the first in the hierarchy to be given an emphasis. Continues and repetitive action for a longer duration can cause fatigue and eye strain. This can be remedied by allowing the staff to have enough rest at regular intervals which are different from the rest hours of the other staff. Their break hours should not be scheduled in the same manner as the rest of the employees because they are performing a different line of work. Checklists and reminders can also be posted at strategic areas around the pharmacy workplace so that the staff can easily glance at them without having to go around. Prescription and dispensation of drugs primarily use the visual organs. Thus, labeling and classification of drugs must be visual-friendly. There are pharmacies that use uniform black labels all throughout the containers and shelves. The worst practise that I consider is that they keep the letters in the smallest point as possible so that more containers can be accommodated in a single shelf. Thus, I strongly agree with the recommendation of some researches that drugs should be color coded according to strength and type, and with variation in the kind of lettering so that pharmacist can easily distinguish one type or group of medications from another. Changing the font size would also help the pharmacists see the drug names especially those below or higher the visual level. Errors may not be totally eradicated in any system. Thus, the system must be reviewed and studied to determine the steps which are prone to error. The study must be done scientifically so that the outcome can withstand scrutiny and would be feasible to implement. Also, more studies must be conducted by health care providers, institutions, scholars and academicians to determine if there are other causes that lead to medication errors, or they may look at other variables which are not yet considered in the current available researches (e.g. the emotion or psychological condition of the pharmacist at the time that lead to error). The staff may be feeling bad that has contributed to his or her mental agility and acuity. As the Nursing & Midwifery Council (n.d.) mentioned in the Standards for Medicines Management, administering drugs is not a mere mechanical action but “requires thought and the exercise of professional judgement” (p.1). Thus, the human element must be considered in the researches on medication errors. The Council’s prescribed standard for nurses can definitely help practitioners reduce medication errors. To end, error cannot be expected to be eradicated totally, therefore, all professional health care personnel at all levels must always be vigilant to that errors can be avoided. References Buckton G 1995. Interfacial Phenomena In Drug Delivery And Targeting, Harwood Academic Publishers, Australia. Chambers CR 2007 April. An Ounce of Prevention: Medication Error Prevention in Oncology Pharmacy Practice. EJHP Practice, vol. 13, pp. 86-87. http://www.google.com.ph/url?sa=t&source=web&cd=38&ved=0CFcQFjAHOB4&url=http%3A%2F%2Fwww.eahp.eu%2Fcontent%2Fdownload%2F25512%2F166764%2Ffile%2FPharmacyPractice86-87(1).pdf&rct=j&q=drug%20error%20in%20pharmacy%20pdf&ei=iZZGTta9DbDymAXRyZz7Bg&usg=AFQjCNGID_FX3RhmxWS0v6lu2Yc_7oixjw&cad=rja [Accessed 4 August 2011]. FDA 101: Medication Errors, 2009 February 20. Consumer Health Information. http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM143038.pdf [Accessed 1 August 2011]. Cina JL, Gandhi TK, Churchill W & Fanikos J. 2006 February. Journal on Quality and Patient Safety, vol. 32, no. 2, pp. 73-80. http://patientsafetyresearch.org/journal articles/Hosp_Pharm_Meds.pdf [Accessed 2 August 2011]. Flynn, EA n.d. A Brief History of Medication Errors. Center for Pharmacy Operations Design. http://www.medaccuracy.com/Papers and Publications/A Brief History of Medication Errors.pdf [Accessed 2 August 2011]. Malseed RT 1990. Pharmacology-Drug Therapy and Nursing Considerations, 3rd edn, J.B.Lippincott Company, Philadelphia. Nursing & Midwifery Council. n.d. Standards for Medicines Management. http://www.nmc-uk.org/Documents/Standards/nmcStandardsForMedicinesManagementBooklet.pdf [Accessed 4 August 2011]. Vadney PJ 2003 Spring. Using Human Factors Engineering to Prevent Pharmacy Dispensing Errors. http://jclauson.com/msqa/term_papers/prevent_pharmacy_dispensing_errors.pdf [Accessed 4 August 2011]. Read More