medication error

medication error

A medication error is a preventable adverse outcome on patients whether or not it is harmful to patients. Medical errors may range from improper diagnosis to the wrong treatment intention that may either cause allergy, syndrome, disease, change of behavior, another disease or ailment, and/or an infection (Senders, 2018). According to CNBC (2018), medical error in the United States it is estimated to cause approximately 250,000 deaths, becoming the third leading cause of death after chronic heart disease and cancer. As a result, there has been increased public outcry to enact strict legislation that protects the safety of patients, thus putting more pressure on healthcare personnel to improve the quality of care to reduce the levels of medical errors. Several tools have been developed to analyze and improve medical errors.

The Root Cause Analysis (RCA) is an approach used by healthcare organizations to retrospectively analyze the events leading an adverse patient outcome in order to establish and address the root causes (Charles et al. 2016). By determining and understanding the root cause of adverse events, healthcare professionals can improve the quality of care by enhancing patient safety and preventing the reoccurrence of a similar event. A successful root cause analysis tool facilitates the designing and development of a solution that addresses the issue at the source (Charles et al. 2016).

From our Scenario of a medical error where our patient is admitted requiring treatment for acute diverticulitis, the PARETO chart medical error analysis within Downtown Medical facility offers the best tool to address the current problem. A look at the chart clearly shows that only three of the possible twelve causes of medical errors account for approximately 82% of the actual medical errors, which implies that focusing on these three causes of medical error will significantly improve the overall medical error cases reported. These leading causes f medical error at Downtown include;

1. Defective scanners –

Defective scanners are the leading cause of medical errors in the Downtown medical facility, constituting over 37% of the medical errors. Our case in hand testifies this belief. The nurse is unable to correctly administer Ultram (Tramadol hydrochloride) 50 mg correctly because the scanner is defective. The defective scanner forces nurses to explore other alternatives for identifying the medication, which involves manual input of the IEN to the computer. The manual input of IEN increases the risk of administering the wrong medication because people are prone to making errors. As noted in our case, after the computer indicates a different medication, the pharmacist advice the nurse that she must have typed the wrong number since the labeling indicated Ultram (Tramadol hydrochloride) 50 mg.

2. Look-alike medication labeling

Sometimes technology fails, and therefore, caregivers must always be cautious when administering medication to patients. The failure of the scanner presents a new challenge to the nurse in this case, and therefore it was important for the nurse to be extra vigilant while inputting the IEN on the computer. At this stage, it is a possibility to think that the nurse inputs the IEN code correctly as indicated in the medication label or interchanged one number; that’s why the computer indicated a different medication that the nurse was advised to go ahead and give the patient leading to an allergic reaction.

3. Pharmacy tech stress errors

Given the priority consideration for patient safety, the pharmacist should never be in a rush to make conclusions. In our case, the pharmacist rushes to advise the nurse to proceed with the administration of the medication despite the computer IEN indicating that the medication was not Ultram (Tramadol hydrochloride) 50 mg.

In conclusion, given that we are not considering technological changes at this point, it is important to improve on lookalike medication labeling because the possible cause medical error may be wrong labeling for lookalike medication that ends up misleading nurses and pharmacists. The Downtown medical facility should also encourage nurses and pharmacists to exercise caution to avoid making rushed decisions when it comes to administering medication. It is important to double-check IEN to ensure the correct information is captured in the event of scanner failure

References

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., … & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery, 10(1), 20.

CNBC. Com . (February 22, 2018). Medical error the third leading cause of death in America. Retrieved from https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html

Senders, J. W. (2018). Medical devices, medical errors, and medical accidents. In Human error in medicine (pp. 159-177). CRC Press.