The essay will examine the management of medicines policy on standards in medication errors by nurses in the hospital environment, the guidelines that nurses must follow when giving medication in order to avoid medication errors. A definition for ‘medication error’ will be given. Further issues to be discussed include; why medication error happens, approaches aimed at minimising medication error and the importance of teamwork , a brief reflection and a conclusion based on the findings will be given. The use of medication process involves different health care professionals as a result , medication error can take place relating to a series of steps in the drug delivery process, and includes the process of prescribing, dispensing, transcribing and administration (Chua et al., 2009 ; Zhan et al., 2006), thereby making room for error to take place. Subsequent to prescribing errors, the administration of medication errors is the most frequent type as they are more likely to reach the patients and the greater chance of causing patient harm (Chua et al.,2009).
The legislation of medicines applies to prescribing, supply, storage and administration and it is important to have knowledge of and adhere to this legislation (Nursing & Midwifery Council (NMC), 2008; Royal Pharmaceutical Society of Great Britain (RPSGB) (2009).
The medicine management policy on standards in reporting medication errors, near misses and adverse drug reactions was located on the Local Trust’s website and was easy to access. The Local trust is an acute, non-profit, health service. From the policy all staff involved in the prescribing , administration, dispensing and checking of medicine has the responsibility to ensure the policy is implemented and adhered to. In the local trust policy it states any member of staff can report a medication safety incident, near miss or adverse outcome. The local Trust Policy was reviewed in January 2012. The trust will also monitor all medication related incidents and an annual audit will be carried out to assess the effectiveness of the policy. The audit will be undertaken on a random selection of 30 cases of reported incidents.
This Local Trust implemented the guidelines for the administration of medicines by the Nursing and Midwifery Council (NMC), 2008 which gives the information a prescription chart must contain for safe and correct drug administration and gives clear principles for prescribing medicines. If the prescription is clear and accurate, errors are less likely to occur. The guidelines also states: “In exercising your professional accountability in the best interests of your patients; as a registrant, you must know the therapeutic use of the medicine to be administered, its normal dosage,side effects, precautions and contraindications,be certain of the identity of the patient to whom the medicine is to be administered , be aware of the patient’s plan of care”
To appreciate medication mistakes and discuss policies for reducing and reporting medication errors, it is useful to understand the term ‘medication error’. The National Coordinating Council for Medication Error Reporting and Prevention states:
‘ a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer’ (cited in Chua et al., 2009 p. 215).
Different standards and policies are formed for varied circumstances and situations as well as routine moments (Unver, 2012). One such standard is the Standard for Medicine Management which replaces the Guidelines for the Administration of Medicines 2004, even though many of its principles remain relevant today (Nursing and Midwifery Council (NMC), 2008. This standard points out the various ways of managing medicine for nurses as they are required to take responsibility for their actions and omissions for any errors they make when giving any medicine (Copping, 2005). Usually, medical mistakes do not harm patients (Department of Health (DoH) (2004). Although, the National Patient Safety Agency (NPSA) (2009) gave a written account that in England, less than 1% of the key instance of harm or death in the National Health Institute (NHS) were directly linked to medication error; 155 medical instances gave rise to severe harm and 42 deaths. Standards in the NHS are used to make sure processes and procedures are carried out in a uniform and consistent manner to help professionals and patients ( Tzeng et al., 2013).
Also , the same process should be carried out in the same way wherever the site or location and under the same circumstance. This uniformity removes errors from personal judgement and panic decisions during situations which could ultimately lead to the death of people under various circumstances ( Fore et al., 2012). The administration of medication is likely to be based on errors in nursing as under normal circumstances, nurses are involved in the administration process and they spend 40% of their time giving it (Wright, 2013; Unver et al., 2012). Hence some studies have reported high error rates, indicating that nurses are putting patients in danger, when such errors would cause a low or minor risk to the patient (Wright, 2013). It is of great value to establish the cause of errors so that solutions can be put in place to reduce medication error rates. Although there are medication policies, adherence to these policies are low (Kim and Bates, 2012).
Prior to medication administration, the following checks should be done : ‘right medication, in the right dose, to the right person, by the right route, at the right time’ (Kim and Bates, 2012) . Despite the guideline established in the administration of medicines using the ‘five rights’, nurses may conduct in a way and give inaccurate assurance that the practice is safe ( Unver et al., 2012). Non-adherence to the ‘five rights’ of medicine administration were observed by Kim and Bates (2012), the observations show that for : wrong dose (1.8%), wrong medicine (13%), wrong time (7.1%), wrong person (5.2%) and wrong route (1.8%).
An observation of potential error in the administration of medicine was made during a recent clinical placement in an elderly ward of a local trust. The ward has 30 beds and medicines were supplied in bulk to the ward, though more specific medicines were provided as single items on receiving a prescription by the pharmacy department. In addition, medication orders were written by doctors directly onto the patient’s medication chart without transcribing.The medication was given by nurses by referring to the medication chart. In view of human error, it was noted that the registered nurses on duty worked over 12 hours a day and Tzeng et al., (2013) noted that taking everything into account nurses function is significantly greater when working a regular 8hour shift compared to over 12hours shift.
Further circumstances that contributed to medical errors by nurses include; tiredness which can affect concentration (Copping , 2005), being distracted or interrupted (Wright,2013; Fore 2013), loss of concentration and a belief about limited drug calculation and numeracy skills among nurses ( Ramjan 2011). In addition, Leape et al., (1995) reported other types of medication errors: short of knowledge of the drug, information about the patient, in breach of the rule, slip and memory lapses, transcription errors, faulty drug identity checking, not interacting with other services, not checking the dose, insufficient monitoring , drug stocking and delivery problems Unver et al., (2012) also noted that medication error can also be as a result of systematic factors like heavy workload ; for example, a study carried out by Karadeniz and Cakmakci , (2002) in Turkey reported nurses fatigue was the primary cause of medication errors. Another factor is insufficient training . It has been well-known that newly qualified nurses lack of skills in clinical settings affects the occurrence of medication errors. A patient’s circumstance, that is complex health conditions), doctor issue (multiple orders, illegible handwriting) and nurse aspect (personal neglect, newly qualified staff, not familiar with medication and patient) .
The avoidance of medication errors is extremely imperative for patient safety (Unver, et al., 2012). In the early 2000s Pape et al., (2005) was the first to initiate the use of aviation’s ‘ sterile cockpit’ code which has gained awareness in the health care to cut down on distraction during clinical tasks. The process included the use of vests and signs. The words ‘Do Not Disturb’ positioned in the medication vicinity were used as prompts to reduce distraction. Members of staff were also asked not to disrupt or distract the nurse doing the medication round of the ward. As a result , Pape’s (2003) study found 63% fewer distraction when using a firm checklist set of rules. Similarly, a study by Federwisch (2008) reported a 50% decrease in the number of staff interruptions, an increase of 50% in the standardisation of medication administration, 15% progress in the time vital to administer medications and 18% increase in on-time medication delivery when nurses wore yellow sashes during medication administration.
On the whole, to lessen medication errors, the collaboration among doctors, pharmacists and nurses is necessary ( DoH, 2004). Doctors must know their shortcoming and recognize their interconnection with other health care professionals (Pedersen et al., 2007), in particular nurse prescribers who help to ease the work of junior doctors. Verification by another nurse is essential as double checking by other nurses in adherence to the ‘five rights’ of medicine administration can help reduce an error (DoH, 2004). Subsequently, pharmacists can lessen the chance of errors by being in attendance on the ward drug rounds and chipping in their drug knowledge (DoH, 2004). Moreover, everyone in the health care team can help reduce medical errors by keeping a reflective journal (Tzeng et al., 2013 ) as a practical self-help tool, though there is a not enough of empirical study to support its valuable effects (Fore, 2013).
According to Fore (2013), health professionals can reflect by one or more of the subsequent methods: welcoming feedback from colleagues about strengths and weaknesses; checks on critical incidents to find out what went wrong , why it went wrong and how to avoid a recurrence of an error; use of a diary for self evaluation and recognize knowledge gaps. It is generally accepted that system factors presents itself with medication errors in health care, nurses are the health professionals that frequently encounter and report medications error ( Roughead and Semple 2008). On the contrary, a study by Unver et al ,(2012) points out, more than half of nurses do not give an account of some medication errors as they are frightened of their colleagues’ reactions. As a result , it is important to foster a culture that is less fixed on laying guilt to promote communication and error reporting. The need to reduce medication error is a continuing process of quality improvement (Unver et al.,2012). According to Sanders (2005) , to establish risk is the first act to undertake, as any other strategy to reduce risk may be inappropriate. This can be made by means of using tools such as audit ( Montesi and Lechi, 2009).
The World Health Organisation’s (WHO) (2009) framework for the classification of problem, process and outcomes of patient safety events is a practical base for a framework to learn the circumstances surrounding medication error. In spite of information of under-reporting of medication errors, especially by physicians, (Franklin et al., 2007) incident reporting can produce an awareness into the errors that happen and make easy identification of contributing factors (Malpass et al., 1999a). Moreover, a UK Government white paper, put forward standardisation of audit as part of professional health care (Montesi and Lechi, 2009). The National Institute for Heatlh and Clinical Excellence(NICE) (2002), defined clinical audit as : “a quality improvement process that seeks to improve patient care through systematic review of care against explicit criteria and the implementation of change” ( cited in Montesi and Lechi, 2009, p. 3).
Clinical audit is a learning tool , which encourages high- quality care and should be implemented regularly and it offers an organised framework for inspecting and judging the work of health care professionals ( Montesi and Lechi, 2009; NICE, 2002). Audit is also a way of measuring and monitoring practice across a well- set of agreed standards and finding mismatches in the written word and actual practice. Similarly, detecting medication errors can also be through a chart review, reporting of incident, monitoring of patients, direct observation and computer monitoring (Montesi and Lechi, 2009). The only technique used for identifying errors of administration of medications is by direct observation ( Montesi and Lechi, 2009). This is done under the observation of a trained nurse by noting the similarity or dissimilarity between what is done in the administration and the original physician orders. In addition to direct observation, reporting systems is another process obtained from procedures in high-reliability organisation.
On the other hand, reports given to legal services can cause confusion and bring about a connotation of blame (( Montesi and Lechi, 2009). Incident of reporting was first used in the UK by the Royal College of Anaesthetists. According to Montesi and Lechi ( 2009), there are two safety-oriented levels of reports. First, incident reporting where it is required that a the details recorded are concise, legible and a true version of events are recorded and sent to the central organisation , which supplies regular statistical reports and raising concerns about quality improvement. Secondly, voluntary reporting . This process is anonymous, confidential and blame- free.The benefits of voluntary reporting include; the detection of active and hidden system failures, evidence of significant processes and the distribution of a culture of safety ( Stump, 2000). Other methods include; patient monitoring, by interviewing, satisfaction surveys and focus groups. Through this, patients can learn about medication errors. With reference the Local Trust Policy, patients now receive an individualised medicine patient information leaflet (PIL) detailing their in-patient and discharge medicine by advising them about any possible side effects and dosage information, contact details should more information be required.
During placement, it was essential that the ‘five rights’ is followed during a medication round with the nurses. It became fully aware that the ‘five Rs’ is the most thorough way to prevent medication error arising. This policy has helped me establish how and why using the correct procedure helps to minimise administration errors from happening. Not all but most of the nurses at the placement adhered to the guidelines that the policy set out. In conclusion, the essay demonstrated that medication administration errors are still a continual problem that is related to practice in nursing . Nurses are mainly involved in medication administration.
They also have an exceptional role of identifying and stopping errors that occur in the various stages. Encouraging patient safety should have a number of approaches that involve more than direct care nursing staff. Another basic cause, is human- factor, therefore a professional education with individuals and system focuses on patient safety matter is essential. Lastly, health professionals accountable for the prescribing, dispensing and administration of medicines must work collectively as team members in the ward environment . The essay also demonstrated how the problem of medication administration error can be dealt with by the National Health Service.
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