Medication Administration Errors in Hospitals-Samples for Students

Question: Discuss about the Incorrect administration of an S8 Medication. Answer: Description The case study is based on an error in medication, which is on an incorrect administration of an S8 drug. The incident involved a newly graduated nurse and Mary who is her colleague. The registered nurse has been working for six months and receiving full support from the Nurse Unit Manager, this implies that, the nurse had some prior experience and knowledge on protocols to be used in drug administration before. The nurse has a good working relationship with the other nurses. During one of her medical rounds in the wards, Mary requested the nurse to conduct an S8 drug check. As the graduated nurse also wanted to administer her patient with the similar medication of S8, she agreed to go to the drug cupboard together. Both Mary and the graduated nurse refer to the medical charts of their patients so that they can know the drugs they were to administer the patients. Mary needed Endone 5mg, she counted the drugs and placed them in the drug cup, similary, she counts the medication needed by the graduated nurses patient, which is Targin 5/2.5mg and places it in a different drug cup. Mary hen locked the medication cupboard carrying with her the medical charts for both patients. Mary and the graduated nurse start by attending Marys patient . They follow the medical rpocedures before giving the patient the medication. On ensuring the patient has taken the drugs, they note on the register before moving to the next patient where they conduct drug check and patient identification. Unfortunately, the graduated nurse realized that they had done an error in medication. the graduated nurse had given Marys patient Targin instead of Endone. Mary questions the graduated nurses competence in handling medication. she feels dispirited but she has to report the incident to the Unit Nurse Manager so that an immediate action can be taken to ensure the safety of the patient. Factors leading to the Incident The major factor leading to the incident is the failure to carry out the three drug check properly. Despite the nurses conducting the drug check, they never did it effectively leading to error in medication. The three drug check requires nurses to check the drugs three times before giving them to the patients, this means that, the drug should be checked before and after administering (Excellence, 2013). The aim is to ensure that the right drug and dosage is administered to the right patient at the right time and through the right method (Westbrook, Lehnbom, Baysari, Braithwaite, Burke Day, 2015). The first check that the nurses should have done was to take the drugs from the medical cupboard and compare it to what is given in the patients medical record to check if they are agreeing. The second check would have been done before giving it to the patient and the third check was to check the drug after administering it to the patient (Kim Bates, 2013). Mary and the graduate nurse cond ucted the first drug check when retrieving it from the medical cupboard, which they compare to what is given in the medical chart. However, the nurse fails o conduct the second drug check which is done right before giving the patient the medication. In this case, the nurse does not identify the correct S8 medication for her patients as she does not take her time to check the drug label for the second time before giving it to her patient. Error in medication can be detrimental, therefore, it is imperative for healthcare providers to conduct the three drug check in order to avoid such mistakes (McLeod, Barber Franklin, 2013). The other factor that had contributed to the error is the failure by the nurses to execute their duties autonomously. Each nurse was assigned their specific patient and each nurse was supposed to administer the S8 medication to their assigned patient. In this case, after taking the drugs from the cupboard, each nurse could have confirmed the drugs meant for their patient . However, this was not done. Mary allowed the registered nurse to administer the drugs on her behalf, which is a mistake. If she had administered the medication herself, she would have been in a better position to identify the drugs before giving it to the patient. therefore, it is imperative for nurses to execute their duties independently to avoid confusions and errors in medication (Alsulami, Choonara Conroy, 2014). Finally, lack of pharmaceutical knowledge played a role in the incident. From the case study analysis, the graduated nurse had been working in the wards for only six months, this means that, she might have lacked the pharmaceutical experience and knowledge in drug administration. Such knowledge is essential for healthcare providers to identify drugs. Therefore, it is important for nurses to enhance their pharmaceutical knowledge to enable them differentiate between medications (Ashcroft, Lewis,Tully, Farragher, Taylor, Wass Dornan, 2015). What I would have done differently In my future practice as a nurse, I will make sure I follow the three drug check to avoid mistakes. For instance, I had two medical cups, therefore, I would have been keen on the drug I was administering to the patient. One of the best way I will do this is by being careful when preparing the medication for my patients and by following drug administration procedures. According to the NSQHS standards on the safety of medication states that healthcare providers should follow the three drug check when giving patients medications to avoid mistakes (Flanigan, 2016). In this case, to avoid such mistakes from happening, first, during the medical checks, I will confirm more than ones to ensure the right patient receives the correct medication. in addition, I will also ensure that I follow the proper procedures when administering drugs, which include giving the right medication to the right patient, at a correct dose, and at the right time. For instance, in the incidence, two patients were re ceiving medication which is almost similar, I would have advised the nurses to label the drugs according to the drug names. By doing so, it would have been easier for the graduated nurse to identify which medication belonged to which patient. In addition, at the bed side before giving the patient the medication, I could have used patient identifiers to enable me identify the correct drug I was giving the patient. the most ideal ways to identify the patient is by checking their identification number or name either verbally, manually, or electronically to ensure the patients details are correct before giving them the medicine. Also, drug confirmation is imperative as it reduces confusions, which can lead to errors (Nanji, Patel, Shaikh, Seger Bates, 2016). In this case, if I was in this kind of situation, I would have confirmed the drugs before giving them to the patients. Alternatively, instead of me giving the medication to both patients, I would have requested Mary to administer the medication to her patient as I did to mine to avoid confusions. In addition, I would have considered revising on my pharmaceutical knowledge in order to broaden my knowledge on drugs and medication. Finally, according to the NMBA codes of professional conduct and standards, it is important for healthcare providers to follow protocol when administering medication (Australian Nursing Council, 2003) . For instance, each nurse was assigned specific patients and no nurse should handle the others patient unless proper communication is given from the doctor. In this case, I would have let Mary to handle her patient as I handled mine in order to avoid confusions. References Australian Nursing Council. (2003).Code of professional conduct for nurses in Australia. Dickson, ACT: The Council, 2(4) 45-98 Ashcroft, D. M., Lewis, P. J., Tully, M. P., Farragher, T. M., Taylor, D., Wass, V., 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). 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