Incident Description

Discuss about Clinical Incident S8 Medication-Nursing Case Study.

To maintain Patient Safety, humans should work in a way that they ensure that the prevention of human errors in medication is maximally minimized. In a health care, the risk of medication incident may occur as a result of many compounded factors. A medication error refers to a situation where a patient ends up receiving inappropriate medication therapy or fails to receive the prescribed medication (Wahr & Merry, 2017). In health care facilities, causes of medication incidents range from many factors. Some of the factors involve working together in the clinical environment as a team. These are one of the experiences that Mary has to encounter with when she asks one of her colleagues to help her administer an S8 drug to a patient.  

The nursing graduate has been working at the hospital for a while and has gained the trust of most nurses and also confidence needed to work the shifts which are mostly fast paced.  This occurs on one busy morning shift when the nursing graduate is required to administer an S8 drug to a patient. One of her colleagues, Mary asks the nursing her to help with the S8 drug check. The graduate nurse gladly agrees since she also requires an S8 drug to administer to her patient. The two proceed to do a routine drug count required before administering the drug.  Mary counts the S8 medication required for her patient and places it into a medication cup (Endone 5mg). She then counts the medication required for the graduate nurse’s patient and places it into a separate cup (Targin 5/2.5mg). They then proceed to administer the medication to the patients, the graduate nurse carrying the two types of medication in separate hands. They start with Mary’s patient, and after completing the patient check and three drug checks, the graduate nurse gives the patient her medication. They then proceed to her patient, and while completing the patient check and drug check, the graduate nurse realizes that she has wrongfully administered the Targin medication to the first patient. She immediately informs her colleague, Mary, who does not take it well and blames her for the error. The graduate nurse is aware that she has to inform the first patient, the doctors and also the Nurse Unit Manager.

Human beings are prone to error; Primary Health Care Remote Obligations requires the reporting of the medicines incidents that may have occurred as a result of error or mishaps in medicine administering. Reporting of these medication errors to the relevant authorities is not meant to punish the clinician involved in particular incidents. But instead, it provides the clinical environment with the necessary information which will be able to build the strategic plan that will aid in minimizing the risks of the same incidents

Relevant Contributing Factors

In any health care facility, the causes of medication incidents can be facilitated by many factors. Some of the readily known factors include. Team work or working environmental factors. In this scenario, the nurses coordinate in working together through administering the medication. While administering the medicine, the person to give the prescription may not be the same person to administer the drugs. In these case, a wrong drug may be administered to a wrong prescription.

Medication errors have become common for not only small hospitals but mostly big hospitals as well (Keers, Williams, Cooke & Ashcroft, 2013).  In most hospitals,   the way the management organizes its organization may contribute to the occurrence of an error. Different tasks allocated to different nurses may bring contradictions in the system. Most error related to adverse drug event is experienced when the relevant medical practitioner fails to make follow up on tasks given to the relevant workers.

One among the prime reasons as to why such an error may occur or in this situation may have occurred in this particular hospital is the distraction (Nguyen, Connolly, & Wong, 2010).  The distraction may have been in various areas. The nurse may have been distracted while her colleague Mary was doing the drug count such that she failed to realize the first drug counted was Endocine while the other was Targin. The graduate nurse may, therefore, have been confused as to where the different medications were placed and only notices this while administering medication to the second patient. The graduate nurse may also have been confused during the time of carrying the medications on different hands such that he may have thought one medicine was the other.

Another common factor that could have caused the error to occur was the lack of adequate knowledge about the different types of medicines by the graduate nurse. A nurse without adequate knowledge about different types of drugs may often confuse between two drugs (Brownell & Priff, 2009). If the graduate were well informed about the types of drugs mentioned in the case study, such an error would have been highly unlikely.  The graduate would have been sure that the drugs she was administering to the first patient were the right medicine instead of realizing that she has administered the wrong medication when it is too late.

Similarly, the nurse may also lack adequate knowledge in the five points of right medical administration. She also failed to perform the three checks before medical administration which requires her to confirm who the patient is, check the medicine that the patient needs and then check the medicine she was administering. Additionally, the similarity of the medicine can be another factor that can cause a medical error as such (Reason & Hobbs, 2017). The two medication may have looked alike and also administered in the same container making it difficult for the graduate nurse to differentiate between the two types of medicine.

Preventive Steps

Finally, the error may be as a result of understaffing in the hospital. Lack of enough nurses could lead to situations that may result in medication errors. Such situations include tiredness that may lead to confusion. Considering that the shifts have been reported to be fast paced as well as busy, the graduate nurse may have been overworked if the hospitals lack enough staff. This would have resulted in the error the graduate made. Lack of enough staff is also a major contributory factor of medication errors (Cohen, 2007).  Additionally, lack of enough staff may lead to one nurse handling a lot of patients and hence a lot of confusion as well as the lack of knowing the patients and their conditions well.

Various preventative steps can be taken to avoid medication errors.  All nurses should aim at preventing a medical error instead of looking for a solution for them (Brady, Malone & Fleming, 2009). To prevent such error, counterchecking the medicine before administering to the patient and ensure that I have given them the right medicine would be paramount to my nursing practice. According to Haw, Stubbs & Dickens (2007), labelling the containers used to administer the medicine is also a great way to avoid such a situation. In case I find myself in such a situation, the first step to rectifying it is to acknowledge my mistake. After telling my colleague, I would then ask her to help me treat the patient who I have wrongly administered the medication. This requires examining the patient for any side effects and then treating them. Administering the wrong medicine to a patient may progress their condition further and even lead to morbidity or mortality. This requires that I have knowledge for treating such symptoms.   I will only do this if there is no physician who is available to handle the situation immediately. 

Through following the channel given out by the Primary Health Care Remote, patients are required   Contacting the attending doctor is the next crucial step in a medical error situation. The doctor will then be quickly required to examine the patient for symptoms of progressed condition or of a newly developed condition.  After the patient is okay, I will then proceed to explain the event to the doctor. I will make it clear to them that I understand what the consequences are and how dangerous my mistake could have been to both the patient and the hospital.  If no serious harm has been done, I will apologize, to both the patient and the doctor.  It is up to them to decide what the next step should be.

Role of Teamwork

If the patient or doctor feel the need to report me to the NUM, I will offer to inform them of the incident myself in writing. The next step will, therefore, be writing a report of the incident. I will write them explaining the situation and giving details of everything that happened. I will then explain to them what I think contributed to my error. This will be followed by a detailed explanation of what I think can be done to prevent such an error.

It is important to remind the nursing board that human beings are prone to error in case of error in medication administration. This may help them understand my situation and chose to forgive me. It is also important that I forgive myself and move past this situation. Such a situation may affect future nursing practice if dwelt on more than it should be.  According to Merkle (2015), many nurses who fail to move past such situations are prone to making more errors like this one in their future. Future nursing recommendations hence include forgetting past situations but ensuring one has learned from them.

References

BRADY, A., MALONE, A., & Fleming, S. (2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of nursing management, 17(6), 679-697.

Brownell, C. & Priff, N. (2009). Nursing2009 graduate drug handbook. Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins.

Cohen, M. (2007). Medication errors. Washington, D.C: American Pharmacists Association.

Haw, C., Stubbs, J., & Dickens, G. (2007). An observational study of medication administration errors in old-age psychiatric inpatients. International Journal for Quality in Health Care, 19(4), 210-216.

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Annals of Pharmacotherapy, 47(2), 237-256.

Kim, K. S., KWON, S. H., KIM, J. A., & Cho, S. (2011). Nurses’ perceptions of medication errors and their contributing factors in South Korea. Journal of nursing management, 19(3), 346-353.

Merkle, W. (2015). Risk management in medicine. Heidelberg: Springer.

Nguyen, E. E., Connolly, P. M., & Wong, V. (2010). Medication safety initiative in reducing medication errors. Journal of nursing care quality, 25(3), 224-230.

Reason, J., & Hobbs, A. (2017). Managing maintenance error: a practical guide. CRC Press

Wahr, J. A., & Merry, A. F. (2017). Medication Errors in the Perioperative Setting. Current Anesthesiology Reports, 1-10