NUR 2407 Module 4 Assignment Safety Risks
NUR 2407 Module 4 Assignment Safety Risks
NUR 2407 Module 4 Assignment Safety Risks
Provide your answers to the following questions in a 2-page paper. Use APA Editorial Format for all citations and references used.
What should the “culture and environment of safety” look like when preparing and administering medications?
Discuss a common breach of medication administration.
Identify three (3) factors that lead to errors in documentation related to medication administration.
What can I do to prevent medication errors?
Medication errors have been a key target for improving safety since Bates and colleagues’ reports in the 1990s characterized the frequency of adverse drug events (ADEs) and the relationship between medication errors and ADEs in hospitalized patients. As described in related primers on medication errors and adverse drug events and on the pharmacist’s role in medication safety, the medication-use process is highly complex with many steps and risk points for error. This primer will focus on nurse-related medication administration errors.
Medication administration errors are typically thought of as a failure in one of the five “rights” of medication administration (right patient, medication, time, dose, and route). These five “rights” have been historically incorporated into the nursing curriculum as the standard processes to ensure safe medication administration. Recent literature, however, has emphasized that medication administration is part of a complex medication use process, in which a multidisciplinary care team works together to ensure patient-centered care delivery. As such, it has been emphasized that the five “rights” do not ensure administration safety as a standalone process. Therefore, four additional “rights” were proposed to include right documentation, action/reason, form, and response.1 As modern healthcare delivery systems continue to evolve, emphasis on system design (i.e. technology & clinical workflows) has become a priority to complement the medication administration process. System-related causes of medication administration errors may include inadequate training, distractors, convoluted processes, and system misconfiguration.2
Despite error reduction efforts through implementing new technologies and streamlining processes, medication administration errors remain prevalent. In a review of 91 direct observation studies of medication errors in hospitals and long-term care facilities, investigators estimated median error rates of 8%–25% during medication administration. Intravenous administration had a higher error rate, with an estimated median rate (including timing errors) ranging from 48%–53%.
A substantial proportion of medication administration errors occur in hospitalized children. This is largely due to the complexity of weight-based pediatric dosing, which encompasses medication doses based on calculations from weight and sometimes height. Variability of weights used for calculation can increase medication dose errors.6 Given this variability, dose preparation is uniquely challenging in pediatric populations, which increases risk for wrong dose administration.
Outside of the hospital setting, patients and caregivers are also at high risk for making errors. Errors in the home are reported to occur at rates between 2-33%. Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors. Contributing factors to patient and caregiver error include low health literacy, poor provider–patient communication, absence of health literacy, and universal precautions in the outpatient clinic.
Prevention
Both low- and high-tech strategies have been designed to ensure safe medication administration and align with the nine rights of medication administration. Many low-tech strategies support all nine rights, including the use of standardized communication strategies and independent double check workflows.
Low-tech solutions
Standardized communication: Health system communication standards are used to ensure right medication. Tall man lettering is used in various electronic health records (EHRs), product labeling, and drug information resources to alert readers to “look alike, sound alike” drug names. Additionally, standard abbreviations and numerical conventions are recommended by The Joint Commission.3 The ‘do not use’ list includes general standards for expression of numeric doses. Of note, leading and trailing decimals (i.e., 0.2mg and 2.0 mg) are discouraged due to the potential for misreading (i.e., 20 mg).3
Patient Education: To mitigate risk of error in the home, it is important for health care professionals to use clear communication strategies and routinely provide education to patients, especially when medication regimens are modified.4 A related primer on health literacy outlines some of the difficulties patients and family members encounter in understanding their medication regimens, as well as interventions for improving communication and understanding.
Patient education is a core component of medication management, particularly with high-risk medications such as anticoagulation therapy. Patients are educated routinely to ensure understanding of indication for therapy, intended outcomes, and signs and symptoms of adverse events. To help mitigate of wrong dose errors, warfarin tablet colors are standardized by their strength across all manufacturers. Patients are often advised to double check their tablet color upon getting a new prescription refill. If the prescription didn’t change, the tablet color shouldn’t either.
Optimizing Nursing Workflow to Minimize Error Potential: In health care settings, distractors during the medication administration process are common and associated with increased risk and severity of errors. Minimizing interruptions during medication administration and building in safety checks through standardized workflows are key strategies to facilitate safe administration. There are many challenges associated with a true distraction-free zone; a study assessing feasibility of a “do not interrupt” bundle found that it was moderately effective but had limited acceptability and sustainability. Areas of increased high-risk medications administrations, such as the intensive care unit or emergency department, may have decreased compliance with non-interruption zones due to workflows and frequency of medication passes and titration events. Health systems should identify the area where medication administration preparation by nurses occurs to ensure that minimal disruptions are present (i.e., medication rooms, medication carts).