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Medication error in clinical practice
The critical incident to be discussed in this assignment is medication error in clinical practice. In the critical incident identification section, I will first describe the incident, reflect on its importance in practice and finally, identify factors that could enhance this aspect of care. My choice of the subject was informed by my great interest in improving medication safety. Throughout the assignment, client confidentiality will be maintained in accordance with the ‘Code’ (Nursing and Midwifery Council 2008). The code emphasizes on safeguarding all personal information such as the client/staff names, address, description, ward name or placement area. Hence, the individual under the discussion has been given the pseudonym of “Bob”.
Bob was on Buspirone (Brand name: Buspar) – a medication used for the treatment of anxiety disorder, or for a short-term relief of the symptoms of anxiety. The medication is generally effective for patients with generalized anxiety or limited degree of anxiety. On the other hand, Buspirone is not very effective with severe anxiety, panic attack or obsessive-compulsive disorder. The starting dose is 10-15 mg daily in two or three divided doses. The maximum adult dose is 60mg daily but most patients respond to 15-30mg daily in two or three divided doses. Buspirone is available as 5mg, 10mg, 15mg or 30mg for oral administration.
Previously, Bob had no problems with his medication regime. However, one day after a registered nurse had administered his afternoon medication, Bob later started to complain about dizziness, drowsiness and cramping pain. Bob also began to show other symptoms like shortness in breathing, coughing sometimes and wheezing. The situation resulted in serious concern as nurses strived to find out what was wrong with Bob. Tests indicated that his temperature at the time was 35.2 degree Celsius, blood pressure 156/87, heart rate 72, respiration rate was 22 breaths per minute and oxygen saturation was 86%. Subsequently, the nurses put him on oxygen to bring his oxygen level to normal. Meanwhile the nurses phoned the emergency services and continued to monitor his respiration, pulse and blood pressure Bob closely. Soon thereafter Bob was rushed to the Accident and Emergency (A&E) wing for further specialized assessment. Upon further investigation, it became apparent that he had taken an overdose. At this stage, the circumstances surrounding the overdose incident warranted critical investigation by the nurse in charge and the line manager.
The policy of the trust is for one nurse to do medication at a set time. The dispensing nurse holds accountability for any incidents that might happen in the cause of dispensing. However, before dispensing high-risk drugs such as insulin, depot injection and intravenous infusions, another registered nurse will always countercheck it before dispensing to the patient. As medication is done electronically in most healthcare settings nowadays, the staff nurse who administered medication to Bob went back to check on the system. She realized that the medication prescribed on the computer was 15mg, but had erroneously dispensed 150mg instead. The nurse admitted to the nurse in charge that she had made a medication error. Pursuant to this, precautions such emergency treatments were taken by the line manager to ensure that ensure the safety of patient Bob. The nurse was encouraged to write a written account and incident report of the event leading to the incident. In line with the trust policy, the staff nurse was suspended pending further investigation. Meanwhile, Bob spent the night at A&E for assessment, after which he was discharged back to the ward. This particular medication error was interesting to me as a nursing student who had never seen a nurse make such an error before. I paused and reflected on the incident, asking myself, how, and why did the medication error happen.
No incident in a clinical practice is taken lightly because patients’ safety is paramount. The National Patient Safety Agency (NPSA) was set up in 2001 to improve patients’ safety in the NHS. According to the recommendation by NPSA (2007), the reduction of medication error was aimed at ensuring safe environment for medication preparation, reduction of distractions and interruption during medication preparation, mandatory double-checking of medication by two separate nurses particularly in high risk medications, and checking if medication had been administered to the proper patient. The report also requires professional such as nurses to help change practice in order to improve safety.
Medication errors made by nurses in clinical practice
Human errors, lack of specialized education and training in nurse prescription have been associated with medication error (Department of Health, 2004). Improving patient care has been a top priority for the government in the United Kingdom. According to the Francis Report (2013), this has been achieved by placing the patient care at the heart of the National Health Service (NHS). Pursuant to this, errors or high profile incidents that happened during nursing/medical intervention or patient hospitalization especially in Winterbourne View Hospital and Mid Staffordshire NHS Foundation Trust, have put the UK’s health sector under increasing scrutiny to improve patient safety and the quality of care (Francis Report, 2013).
The National Coordinating Council for Medication Error Reporting and Preventing (NCCMERP) (2012, p.4) defines medication error as “any event that is preventable that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or a consumer”. The Institute of Medicine (2006) identify wrongful hospital infections, wrong equipment, pressure sores, workload, inappropriate management of clinical situations and medication errors as some of the common errors occurring in the healthcare environments. A study by Cohen (2007) noted that medication errors are usually categorized according to the description of the event such as omission error, wrong drug error, wrong time error, wrong route, wrong technique error, wrong dosage-form error and extra dose error. According to Ghaleb et al. 2010, the process of medication, which takes different stages of prescribing, transcribing, dispensing, administration and monitoring has proven to be susceptible to medical error. For instance, it is commonplace for nurses to administer a wrong medication to patients. Hence, to enable the nurses to avoid these errors, it is undoubtedly relevant to implement or reinforce preventive measures in the healthcare setting
Nurses should take into account all precautions for medication error by firstly decreasing the incidences, keeping the culture of safe hospitals environment and ensuring a safe medication management. The protective measures against medication errors are linked with the preparation and administration of medications i.e. how the health team works efficiently towards medication management so as to promote patient safety (Health Science Journal, 2012). Nevertheless, in order to build a safer NHS for patients, there is the need to improve medication safety by outlining the extent of the problem and clearly describing how a medication error can develop through prescribing, dispensing and administration (Department of Health, 2004). In 2007, the National Patient Safety Agency reported that medication administration represented 59.3% of medication errors; preparation and dispensing accounted for 17.8% of the errors, while prescribing represented 15.7%. The most common incidents reported by NASPA (2007) were wrong dose (strength or frequency), omission and wrong medicine that all accounted for over half (57.3%) of all medication errors.
Methodology
The author of this research reviewed numerous literatures to explore medication errors, and what could be done differently to avoid it from happening in the future. The databases the author searched included British Nursing Index (BNI), CINAIL and MEDLINE. BNI covers all major British nursing publications while the CINAHL Plus and Medline cover various medical and nursing journals based in the United States. Keywords in the search terms such as “Solution OR Prevention OR Reduction OR Intervention in combination with “Medication error in clinical settings” were used. The inclusion criteria incorporated studies produced in English and ones that were published between 2000 and 2013 using all age groups with linked full-text and studies in the western society, Australia and United States of America. Research materials irrelevant to British healthcare setting, extensively technical data or those focusing on specific incidents such as medication error in chemotherapy and diabetes were excluded. The inclusion criteria enabled the researcher to include studies focusing on the prevention of medication error with direct relevance to the nursing practice. As such, various articles were reviewed, selecting twelve that met the criteria. The findings require generalizing the nurses in clinical setting and focusing the search onto the attributes of medication errors in the NHS.
Discussion
The discussion for this study focuses on pieces of research by assessing the type of evidence used and identifying the findings. Then individual articles will be critically appraised and linked to how Bob’s medication error can be addressed. Thus, research review of medication error focuses almost exclusively on the patients in clinical settings.
First article
The first article discussed is titled “Reducing medication administration errors in nursing practice” by Jones (2009). Manias et al. 2005) conducted the research using a prospective cohort study designed using qualitative participant observation and questioning of nurses during medication administration. The research sampled 12 graduates’ nurses to ascertain how they used protocols in clinical practice. The findings indicated that some nurses checking patients’ identity relied on how long they have known them. In one instance, it was observed that while patient’s identity band was almost illegible, the nurse in question did not change it.
Research of policies and protocol regarding medication error was also reviewed. Hand and Barber (2000) in their study conducted semi-structured interviews of 17 nurses from various specialties with different grades to find their thoughts about medication error. The findings showed nurses cited personal factors as the main reason for the occurrence of medication error. The nurses gave example of not reading prescription properly, not reading dose properly and frequency or time correctly.
In another study, Sanghera et al. (2007) interviewed staff involved in reported and non-reported medication errors on a 12-bed intensive care unit. The feedback revealed that the staff did not often refer to policy while undertaking their clinical duties. For example, intravenous policy was highlighted as a task related error-producing situation as defined by Reason (2007), whose work provided the framework for the research. Similarly, Jones (2009) points out that nurses sometimes ignored policies and protocol in clinical practice. When policies and protocol are not followed, there is the likelihood of wrong medication administered to patient. Though a single nurse medication administration is accepted in UK, a second checking is advisable in some situations (for example insulin) which are intravenous or where complex calculation is needed. The participants of the studies identified that the role of second checker of medication was not clear, as nurses’ understanding of second checker was different because the policy did not clarify what the second checker should be checking
Manias et al. (2005) use of prospective cohort studies gives some strengths to the research. This is because it can assess several outcomes, establishes sequence of events and can subsequently measure variables at ends. However, the main weakness of the study was that it was conducted in Australia, where the policies applicable in that country may be different from UK. In addition, there is greater risk of respondent bias because the participants may have vested interests.
Relevance
In relation to the critical incident of Bob, this study has significant correlation because if the policy made medication administration mandatory for a second checker to verify every mediation administered, the patient might not have been administered a wrong medication. while a second checker of medication administration is not an absolute guarantee to preventing medication incidents because, it could substantially limit the likelihood of errors happening.
The second article
The second article to be analyzed was a research carried out by Taxis and Barber (2003) entitled, “Causes of Intravenous Medication Error.” This was an ethnographic study that adopted a purposive sampling strategy to collect data in a range of different hospital settings (a university teaching hospital and non-university teaching hospitals) in United Kingdom. The studies were conducted at 10 wards in two hospitals, involving 113 nurses over 76 days. The result of the observation was that there were a total of 483 IV drugs preparation and 447drug administration incidences of which 256 errors were identified. It was recognized that the most common form error was the intentional violation of guiding principles by injecting boluses faster than the recommended speed of 3-5 minutes. The cause of this was inadequate knowledge of preparation or administration the complex design of equipment. The fundamental difficulties were the cultural context allowing unsafe medication use, failure to impart practical aspect of drug handling and design failure. There were 25 (representing 10%) slips and lapses, 60 (representing 23%) mistakes, and 171 (representing 67%) violations
Strengths of the study
The strength of the study was, firstly, it provided a comprehensive viewpoint than the forms of educational research. Secondly, it is suitable way of studying behaviors best understood in their natural settings. The research was a first-hand observation, usually conducted over an extended period of time. Finally, the research can evolve new lines of enquiry.
Limitations of the study
The study had such limitations as high reliance on the observations made by the researcher. Furthermore, some bias of the observer was not possible to get rid of while the nature of the research made it difficult to generalize the study.
Third study
The study to be analyzed was one undertaken by Wright (2006) titled “Barriers to Accurate Drug Calculations”. The study investigated the effectiveness of implementing strategies such as mathematical and conceptual skills, which aimed at developing the mathematical and conceptual skill of student nurses to enable their medication calculation skills, so that they can interpret clinical data into drug calculations to be solved. The study employed a quasi-experimental pre and post design to investigation the numeracy skills of 71 nursing students in the United Kingdom. The participants were given 30 drug calculation questions as a test to evaluate a number of strategies to enhance mathematical ability. This comprised of online mathematics sessions, 2-hour lecture, workshop, lectures and private study. Many of the participants, 96% (n=68) had unsatisfactory mathematics skills because they were unable to answer 75% of the questions correctly. The test was done again after 7 months and there was a noticeable improvement about 82% (n=58) getting more than 75% of the answers correct. The study found that the strategies that focus on developing mathematical and conceptual skills are effective in improving calculation skills of nurse. The study also shows that a range of strategies has the potential ensuring that the student nurses retain the skills taught. According to Eisenhaur et al. (2007), good knowledge of medication, dosing calculation skills and nursing education is a protective measure against medication error.
Results of the study
The results of the study replicate similar findings of studies conducted by Grandell-Niemi et al. (2006). Generally, they emphasized that improving calculation skills has the potential to prepare nursing students to be efficient in their clinical duties afterwards. The students noted that nurses and student nurses needed to improve their knowledge in pharmacology considering that calculation skills and proficiency is a prerequisite to perform well in the medication calculation.
Strengths of the study
The study has a number of positive qualities. First, he researcher gained the consent of the nurses and student nurses, which is important in ethical research (Salize and Dressing, 2005). Second, through the chosen quasi-experimental design pre and the posttest, the researchers were able to understand the improvement of the calculation skills of the participants.
Limitations of the study
The limitations of the study included small sample size which rendered it difficulty to generalize the results. In addition, the improvement in the result cannot be attributed to the strategies alone.
Relevance
This research is applicable to the critical incident of Bob as it clearly addresses medication calculation skills that could have been the consequence of the prescribing nurse administering wrong medication to Bob.
Fourth article
The fourth article analyzed was Maidment et al. (2006) entitled “Medication error in the mental healthcare: a systematic review”. The article is a systematic review of quantitative studies. Systematic reviews provide a rigorous approach to combining findings across several studies. This follows a structured protocol that is designed specifically to control various types of bias that can threaten the review process (British Journal of Midwifery, 2012). Evidence hierarchies are normally used as framework for ranking the evidence for healthcare interventions. Quantitative research collects statistical data that measures quantities and relationships between attributed, by providing efficient, reputable and factual information of the research (Parahoo 2006, Bowling, 2005).
Purpose of the study
Maidment et al. (2006) study aimed to investigate medication errors in mental health acute settings. To the best of the author’s knowledge, there had not been any previous systematic review of medication error in the mental healthcare settings. This necessitated conducting a literature review to explore medication error in the mental healthcare. According to Maidment et al. (2006), it has been estimated that medication errors 1-2% of patients admitted to general hospitals. Consequently, the medication errors that have the potential to cause harm or death in the mental healthcare was unknown.
Nirodi and Mitchell (2002) conducted a study from 1991-1997 in National Health Service (NHS) mental health inpatient unit for older people. The design of the study and data source was a retrospective process, all prescription charts for 112 patients. The study found out that 92 patients’ prescription contained errors but there was no information of harm reported by the errors. According to the Royal College Psychiatrist (RCP, 2006), in mental health, medication is used in managing acutely disturbed behavior. RCP (2006) reiterates that there is good evidence that monitoring a patient is not adequate after giving medication despite the possible association between rapid tranquilization and death from cardiovascular event. Cunnane (1994) as cited by Maidment et al. (2006) asserts that some patients with mental health problems may be less articulate and less likely to question their prescription, change in medication regime and possible side effects.
Systematic Reviews of the study
Systematic reviews are based on literature review, which looks closely to a set of scientific methods that clearly aim in limiting systematic error, mainly by attempting to identify, appraise and synthesize all the relevant studies in order to answer a specific question (Green, 2008). Wendt (2006) argues that systematic literature review is important research technique. By using this method, the researchers increase the rigors of the study. Rigor in research study means the application of appropriate techniques to meet the objectives of the study and the level of precision in the analysis of the data (Ryan, 2010). The method of the research is reliable and the results are precise because it utilizes a diverse range of research work that has been complied by a wide range of researchers (Moher et al, 2007). However, there was limited research of systematic review on medication error in the mental health setting. Hence, this might be owing to limited focus of the research. The trend of retrieving information can be difficult if the data is not available or consistent across the selected studies.
Relevance
The research is relevant to the critical incident of Bob since it examined the medication error in mental healthcare as the patient concerned is a mental health patient and is less articulate and less likely to question his medication. There are some constraints, which makes it difficult for nurses reporting errors identified. These comprises include fear of disciplinary action, inability to report anonymously, constraints of time and considering it unimportant because they have no consequences. Mayo and Duncan (2004) identified that 50% of nurses did not report medication error for the fear that it would bring negative repercussions on them
Fifth article
The last article to be discussed was “Medication Error Reporting: A Survey of Nursing Staff”, a descriptive quantitative survey carried out by Antonow et al (2000). The study aimed to investigate medication error, focusing on the extent of reporting an error in the health setting. The investigation was centered on the four stages of medication: prescription, transcription, dispensing and administration. The study consisted of 72 registered nurses who had mandatory skill training in a 38-bed pediatric unit. The skill training was compared to incident reports and medication error in the past 6 months. The researcher classified the most recent medication error of each of the four stages as to nature, timing, whether the error was avoided from reaching the clients. The response rate of the survey was 93.5%. The researcher identified 177 errors, 40.3% witnessed medication error in the preceding week, and 62.1% errors never reached the patient and the likelihood of prevention was reduced from later stages of the medication error. Around 30% of the medication errors resulted in incident reports. Administration errors accounted for 51% of incident reports compared with ordering errors, particularly when the error was not prevented from the patient.
A multi-variety logistic regression with completed incident reports as the dependent variable showed a reduced possibility of incident reports for ordering errors than administration. The findings of the study showed that augmenting incident reporting of medication errors and classifying errors by stages, anonymous medication error survey can help for monitoring and guiding improvement in hospital medication systems.
Strengths of the study
Some qualities of the survey design include collection of primary raw data from participants, ability to accommodate large sample size, and generalization of results. In addition, there was the ability to differentiate between small and complex diverse sample groups.
Limitations of the study
The study had such limitations as greater risk for remember bias, as well as under and over estimation of error.
Conclusion
The conclusion aims to summarize the articles previously discussed, and compare the results with the critical incident identification, their relevance to Bob’s medication error, and what could have been done differently to avoid it happening in the future.
Firstly, it could be deduced that the findings of the research suggest that there is a variety of evidence to reduce medication error. It asserts that nurses must adhere to effective policies and protocols in clinical practice. When medication protocols such as the “five rights” are followed, it can ameliorate medication error and enhance patients’ safety. A second checking of medication is not completely guaranteed to prevent medication error, however there is evidence that it could reduce medication incidence
Secondly, it is apparent that there is need for nurses to have good knowledge in preparing and administering medication by having skill sessions or training to boost their knowledge, hence reducing medication error in healthcare settings. In addition, the study by Wright (2006) proofs that nurses should develop their mathematical and conceptual skills to enable them to prevent medication error. Also, there has been an emphasis that it is significant for nursing students to improve their knowledge in pharmacology to prepare them for the clinical task ahead. Furthermore, medication error in mental health sector needs to be addressed to improve patients’ safety as Nirodi and Mitchell (2002 identified medication incidents which was not critically analyzed. Maidment (2006) observes that some mental health patients are less articulate and have difficulty in understanding their medication. Consequently, there is evidence that giving patients their medication is not enough since they need to be monitored closely to enhance their safety.
Finally, nurses should be encouraged to report every incidence that happens in practice. In this regard, failure to report incidences for fear that disciplinary actions, facing negative repercussion against them should be discouraged. The study from the last article highlighted that medication administration accounted for 50% of errors in the stages of medication.
