Medication Errors: Let’s Chat

Gilberto Buzzi,

Guest Host of #ebnjc Twitter Chat on Wed., June 21 at 8pm UKM time

Senior Lecturer – Adult Nursing, School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 0AA, t: +44 (0)20 7815 6739 | e: buzzig2@lsbu.ac.uk

Medication Errors

Ever experienced the terrors of been involved in a medication error, particularly one that had the potential to result in patient harm? If so, it is likely that you remember that moment quite vividly which may even have left you traumatized. These are some of the worse situations healthcare professionals may find themselves in as it goes against every core principle of their moral and professional duty. An entire section of The Code for Nurses and Midwives is dedicated to the preservation of patient and public safety and the importance of self-awareness to reduce potential harm associated to their practice (NMC, 2017), nonetheless, medication errors are still common.

In a review of medication error incidents reported to the National Reporting and Learning Systems (NRLS) over six years between 2005 to 2010 there were 525,186 incidents reported. Of these, 86,821 (16%) of medication incidents reported actual patient harm, 822 (0.9%) resulted in death or severe harm (Cousins et al 2012). A report commissioned by the Department of Health estimated the costs of preventable errors in the NHS, particularly relating to improper use of medication, to be around £770 millions a year, but most importantly, medication errors can cost lives.

“Medication errors occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death” (WHO, 2017). This suggests that medication errors could be preventable at different levels. Whilst there is robust legislation and guidelines to ensure patient safety particularly in relation to the administration of medicine, following simple and practical steps such as the 10 rights of Medication Administration can greatly reduce the risk of errors and literally save lives. These are:

  1. Right patient: Ask patient to identify themselves and check the name on the prescription and wristband. Ideally, use 2 or more identifiers.
  2. Right medication: Check the name of the medication and the expiry date with the prescription. Make sure medications, especially antibiotics, are reviewed regularly.
  3. Right dose: Check appropriateness of the dose using the BNF or local guidelines. If necessary, calculate the dose and have another nurse calculate the dose as well.
  4. Right route: Again, check the order and appropriateness of the route prescribed.
  5. Right time: Check the frequency of the prescribed medication. Confirm when the last dose was given.
  6. Right patient education: Check if the patient understands what the medication is for and who to contact in case of side-effects.
  7. Right documentation: Ensure you have signed for the medication AFTER it has been administered. Ensure the medication is prescribed correctly.
  8. Right to refuse: Ensure you have the patient consent to administer medications.
  9. Right assessment: Check your patient actually needs the medication. Check for contraindications. Baseline observations if required.
  10. Right evaluation: Ensure the medication is working the way it should and reviewed regularly. Ongoing observations if required.

Points 1 to 5 refer to NMC standards for medicine management. Points 6-10 are additional checks that have been adopted by multiple US nursing boards and research panels to enhance patient safety.

References:

Cousins, D.H., Gerrett, D. and Warner, B. (2012) A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010). British Journal of Clinical Pharmacology, 74(4): pp. 597–604

Frontier Economics (2014) Exploring the costs of unsafe care in the NHS. [online] London, pp.1-21. Available at: http://www.frontier-economics.com/documents/2014/10/exploring-the-costs-of-unsafe-care-in-the-nhs-frontier-report-2-2-2-2.pdf [Accessed 10 Jun. 2017].

Nmc.org.uk. (2017). Read The Code online. [online] Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ [Accessed 10 Jun. 2017].

World Health Organization. (2017). Medication Without Harm: WHO’s Third Global Patient Safety Challenge. [online] Available at: http://www.who.int/patientsafety/medication-safety/en/ [Accessed 10 Jun. 2017].

Standards for medicine management: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-medicines-management.pdf

Report a problem with a medicine or a medical device: https://yellowcard.mhra.gov.uk/https://yellowcard.mhra.gov.uk/

Medicines & Healthcare products Regulatory Agency: https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency

Interesting read: https://www.zebra.com/content/dam/zebra_new_ia/language-assets/en_gb/solutions_verticals/Verticals_Solutions/healthcare/guide/mobile-printing-solutions-guide-en-gb-emea.pdf

https://www.england.nhs.uk/wp-content/uploads/2014/03/psa-sup-info-med-error.pdf

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=68464&type=full

http://www.pharmaceutical-journal.com/news-and-analysis/medication-errors-cost-the-nhs-up-to-25bn-a-year/20066893.article

 

 

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