Description

Investigate the Erroneous Administration of an S8 Medicine.

The case is on an investigation on the erroneous administration of an S8 medicine. It includes a recently graduated nurse on her first medical rounds on the wards. The nurse has an experience working in wards as she has been there for almost half a year and she has had the help and support of the Nurse Unit Manager. The nurse has a great working association with the other healthcare providers and she feels sufficiently competent with the skills she had acquired over the months she had been in the facility. In addition, the fast shifts she has had have likewise added to her working knowledge and she finds this to be extremely intriguing.

Amid one of the morning shifts, while doing her medicine rounds, Mary, an associate of hers inquires as to whether they could do an S8 drug check together. Since she needs a similar medication, she goes to the S8 cupboard with Mary. The two allude to their medical charts and the S8 book with the aim that they get the needed drug for their patients. Mary counts the required drug of S8 for her patient, Endone 5mg and places it in a medical container and after that, she checks the medicine required for the attendant’s patient, Targin 5/2.5mg and places it in a different container to avoid confusion (Westbrook & Day, 2015). She bolts up the S8 cabinet and takes with her the patient’s medical chart while the attendant carries the medication containers.

The two nurses start by going to Mary’s patient. They follow the medical measures by first finishing the patient checks and three medication checks and after that, the new attendant hands the patient the medical container with the tablet in it. On ensuring that the patient has taken the tablet, they both sign the S8 book to enlist that the patient had their medication. The two medical attendants at that point begin to make drug check and patient identification. Unfortunately, the new attendant notes that the medical container had the Endone tablet rather than the Targin tablet meant for her patient, which they had administered to Mary’s patient. The new attendant informs Mary that she gave her patient the wrong S8 drug and Mary questions her ability in taking care of patients’ medication. The new medical attendant feels demoralized, however; she should inform the affected patient, the Unit Nurse Manager, and the doctor in charge immediately with the aim that necessary steps are taken to secure the patient’s well-being.

What happened and why it happened

The principle factor for this situation is the Nurses insufficient consideration preceding the administration of the medications. As indicated in the case, the new attendant just checked the medicine in the container before she offered it to the second patient and that is the point at which she saw it was not the correct medication. If she had focused on the substance in the medical container while administering it to the patient, at that point the mistake would have perhaps been avoided. In this case, she would have paid attention while administering the medicine would have prevented the errors from occurring. In addition, if Mary were keen, she would have seen the medicine that the new attendant was giving the first patient and she could have affirmed regardless of whether it was the correct one preceding the patient took it. The new attendant could have likewise focused on the medications meant for the patient before administering them to the patient; this is vital in preventing errors in medication (Westbrook & Day, 2015).

The other likely factor that could have been knowledge based on the case analysis is that the nurse has experience working in a ward yet there could be plausibility that she does not have the sufficient medical information. This sort of information and experience could be extremely valuable in recognizing the prescription easily even without being keen on the drug she was administering. For this situation, medical knowledge and experience would have helped the attendant to distinguish between the Targin 5/2.5mg tablets and the Endone 5mg tablets through their shape and color. In this way, it is essential for the attendant to consider checking the description of the medication before offering it to the patient. Further, it is critical for the attendant to increase her knowledge on drugs with a specific end goal to guarantee proper medications.

Another factor that could have added to the incident is a mistake in executing their obligations independently (McLeod, Barber & Franklin, 2013). Each of these attendants had their particular allocated patients, and it is required that each attendant ought to direct medicine to their assigned patient. On the off chance that in the wake of taking the pharmaceuticals from the pantry, each of these attendants had taken the container that contained the essential solution and affirmed that they had conveyed the right prescription exclusively, they would have evaded the off base organization (Nanji & Bates, 2016). When they got to the principal tolerant, Mary let the new attendant manage the solution to her patient as opposed to doing it without anyone’s help. On the off chance that she had done it independent from anyone else, she could have possessed the ability to differentiate the medicine that the patient was getting (Kooke, Walsh & Ashcroft, 2014). The two attendants made a mistake in doing their obligations since they did not direct the medicine as required. In this manner, it is imperative for the attendants to consider do their obligations autonomously as opposed to assigning out them to others to evade oversights and disarrays like the ones experienced (Keers, Williams, Cooke & Ashcroft, 2013)

What I was to do differently

If I was the attendant who directed the wrong S8 medicine, there are things that I would have done another way to stay away from the incident. First, I would have been enthusiastic about the prescription I was providing for the patient particularly considering I had two medicine containers with various S8 drugs. In this case, it is vital to counter check medicine before administering them to the patients (Excellence, 2013). After affirming the patient’s identity and medicine, I would proceed to check the tablets in the medical cups are the right ones as per that specific patient’s medical chart. The National Safety and Quality Health Service (NSQHS) standard 4 require the clinical workforce to be skilled to ensure the safe administration of drugs (Kim & Bates, 2013).

Second, while administering medications, it is required for attendants to stick to convention thus failed to follow the convention brought about the error in medication (Banks, 2016). In this way, as the registered nurse, I would have demanded giving Mary a chance to handle her patient as I also handled my patient. Subsequent, on getting the medication from the cupboard, I would have affirmed the drug for my patient then I would have given Mary the other medical container containing her patient’s pills. Further, the assigned nurse has the obligation of guaranteeing they direct medication to their patients according to the convention’s guidelines. Therefore, I would have given Mary a chance to administer the medication to the patient. The NSQHS guidelines on the safety of medication direct that the clinical workforce needs to maintain appropriate convention when administering medication Alsulami, Choonara & Conroy, 2014). In addition, I would have considered my medical knowledge on the S8 drugs being administered to the patients. Pharmaceutical information and experience has been found to diminish the errors in medication in the clinical settings (Ashcroft  & Dornan, 2015).

References

Ashcroft  & Dornan, T. (2015). Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. Drug safety, 38(9), 833-843.

Alsulami, Z., Choonara, I., & Conroy, S. (2014). Pediatric nurses’ adherence to the double?checking process during medication administration in a children’s hospital: an observational study. Journal of advanced Nursing, 70(6), 1404-1413.

Banks, M. (2016). ISQUA16-2476 IMPROVING THE SAFETY AND QUALITY OF HEALTH CARE FOR ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE USING THE AUSTRALIAN NATIONAL SAFETY AND QUALITY HEALTH SERVICE STANDARDS. International Journal for Quality in Health Care, 28(suppl_1), 55-55.

Excellence, B. P. (2013). The Joint Commission announces 2014 national patient safety goal. Joint Commission Perspectives.

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug safety, 36(11), 1045-1067.

Kooke, J., Walsh, T., & Ashcroft, D. M. (2014). Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review. Drug safety, 37(5), 317-332

Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to guidelines. Journal of Clinical Nursing, 22(3-4), 590-598.

McLeod, M. C., Barber, N., & Franklin, B. D. (2013). Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf, 22(4), 278-289.

Nanji & Bates, D. W. (2016). Evaluation of perioperative medication errors and adverse drug events. The Journal of the American Society of Anesthesiologists, 124(1), 25-34.

Westbrook & Day, R. O. (2015). What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. International Journal for Quality in Health Care, 27(1), 1-9.