Clinical Risk Management
Context
Medication administration errors in healthcare pose severe risks to patients. During clinical placement, I witnessed an incident involving a mistake in medication administration that could have potentially been fatal. While working at the cardiac intensive care unit, a 56-year-old woman was put under our care. She had suffered a massive heart attack a few days prior, and her condition had improved considerably since her hospitalization. She was due to be moved to the general ward the following day. Three nurses were working in the unit that day, myself included, and a total of four patients. By the time of the incident, we had worked for close to ten hours. We were tired, but the patients were stable, and the unit was calm.
At around 3 pm, the nurse in charge of medication rounds for the day began to prepare medications for the four patients. The med room is open to the nursing station, so she continued interacting with the rest of us. We laughed and talked as she dispensed the medication. The 56-year-old patient was supposed to receive a dosage of Thiazide. It was evident that the nurse was distracted during the process, and she failed to pay close attention to what she was drawing up in the syringe. She proceeded to administer the medication to the patient. Almost immediately, another nurse from the desk called out to her and asked her to look at the monitor.
The patient’s blood pressure had dropped rapidly and significantly since she began administering the medication. She immediately looked down at the syringe and realized that she had injected the patient with double the required dose. Thiazide is a powerful diuretic, and an overdose can cause severe symptoms. The nurse immediately broke down, realizing the danger she had put her patient in and was unable to act. The other nurses and I stepped in right away to try and salvage the situation and undo the effects of the incorrect dosage. It took over four hours to stabilize the patient and deal with the other symptoms, including irregular heart rhythm and weakness.
The patient had to spend an additional three days in the cardiac intensive care unit, but we were able to prevent the more severe impacts of thiazide overdose, such as seizures and a coma. The nurse who made a mistake was inconsolable and had to undergo counseling to deal with the guilt that came with almost killing a patient. The incident was a wake-up call to other health care workers in the hospital on the importance of paying close attention during medication administration. We also learned to respect the process of medication administration by allowing the nurse in charge of this role to entirely focus without any distractions.
Clinical Risk Management Process
Identification
Medication administration errors can occur due to five distinct failures that are directly related to the “rights” of medication administration. These are:
- administering medication to the wrong patient
- administering the wrong medication
- administering the wrong dose
- administering medication at the wrong time
- administering medication through the wrong route
Medication administration errors in practice are identified through observation, self-reports, or observing patient outcomes. In cases such as the exemplar provided above, the error is distinguishable immediately. In other cases, when patients fail to show symptoms or when health care workers are oblivious of their mistakes, such errors can go unnoticed. Monitoring and reporting the occurrence of medication administration errors is one of the functions of the Drug and Therapeutics Committee within a health care organization. The committee then uses this information to ensure that such mistakes occur as rarely as possible. All medication administration errors should be recorded and compiled into a monthly report (Holloway & Green, 2003). The report should contain general information about the error, but should not make mention of the individual responsible for the failure. This report aims to identify patterns of error within an organization to modify managerial and environmental changes that may be fostering the mistakes.
Analysis
Different health organizations and researchers report varying rates of medication administration errors. A 2013 review of 91 direct observational studies on medication administration found error rates to be between 8% and 25% (Keers et al., 2013). The review further found the most common error to be administered at the wrong time. The rates of failure were higher during intravenous administration, and Keers et al. estimated the median price to be between 48% and 53%. McDowell et al. (2010) estimated that there is a 73% chance of an error occurring during intravenous medication administration. The World Health Organization reports varying error prevalence rates in different parts of the world, depending on studies conducted there. The organization, however, states that serious medication errors are few. However, considering the substantial amount of prescriptions issued in primary care, there is still potential to cause significant harm to patients (World Health Organization, 2016).
The United States Food and Drug Administration lists some of the harmful effects of medication error and includes hospitalization, life-threatening situation, disability, and death (Food and Drug Administration, 2019). Tariq & Scherbak (2019) report that between 7,000 and 9,000 people die as a result of medication error in the United States each year, and the most common type of error is drug overdose. They further report the psychological and physical pain patients experience due to adverse reactions and other complications related to the medication. Children and elderly patients are more sensitive to medicine, and errors in these populations can have severe consequences.
Evaluation
The World Health Organization (2016) states that evidence supports the use of a multifaced intervention for improving medication administration processes. The following approaches can be implemented to reduce the risk of errors in practice:
- Reducing Distractions
Distractions have been identified as a primary cause of medication administration errors. Tariq & Scherbak (2019) estimate that distracted health care workers cause almost 75% of medication errors in the clinical setting. The use of nursing tabards with the inscription “do not disturb” by nurses during drug rounds is effective in preventing interruptions and medication administration errors (Verweij et al., 2014).
- Avoiding Distortions
Distortions are another cause of medication administration errors. Deformities can be caused by illegible writing, unclear symbols, the use of abbreviations, or incorrect translation (Tariq & Scherbak, 2019). A policy that enforces the use of electronic medication orders in place of handwritten orders and prescriptions can aid in reducing miscommunication between different clinicians.
- Cognitive Aids
Cognitive failures in working memory and attentiveness also contribute to medication administration errors (Wondmieneh et al., 2020). These failures are particularly common in stressful situations such as emergencies and during staff shortages. Cognitive aids can be used to counter these failures. Alidina et al. (2018) report that cognitive aids such as checklists and physical reminders (i.e., posters) improve judgment and decision-making during clinical crises.
- Education
Educating primary health care workers about medication administration errors can help prevent common causes. Training can also encourage clinicians to be more cautious and mindful during the medication administration process to prevent carelessness, forgetfulness, and negligence.
- Adopt a reporting system
A reporting system that records all medication administration errors, even near-misses, is valuable for preventing the reoccurrence of similar mistakes. Clinicians should be encouraged to report these errors without fear of repercussions. As Tariq & Scherbak (2019) state, this is a great learning experience that improves safety.
- Bar-coding System
Weant, Bailey, & Baker (2014) recommend the use of bar-code medication-administration systems in reducing rates of error. The systems work by assigning a unique identifier on each medication and patient (Weant et al., 2014). Health care workers scan patient and medication codes to ensure the rights of medication administration are met. Implementing technology into the administration process can help prevent common errors.
Management
Nurses are primarily involved in the administration of medication in clinical settings (Hughes & Blegen, 2008). They are responsible for ensuring the five rights of medication administration are adhered to, along with institutional policies on medication administration. Working conditions facilitate medication administration errors. Nurses can identify and work towards mitigating conditions that predicate medication administration errors. Hughes & Blegen (2008) recognize three conditions that nurses can address. Latent conditions relate to organizational processes and other aspects of the system that result in issues such as staff shortages, fatigue, high turnover, and a lack of medication administration policies and protocols. Error-producing conditions focus on the individual, team, and environmental elements that may impact performance, such as distractions, excessive noise, poor lighting, and frequent interruptions. Active failures involve cognitive lapses, slips, and mistakes. By recognizing and monitoring these conditions, nurses can help create working conditions that preempt errors.