Medication Error Scenarios
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Insights Blog Special Reports Quizzes and Surveys Video Library Safe patient handling and mobility: The journey continuesPatient handling injuries: Risk factors and risk-reduction strategies Magnet® Search for:Advanced Search HomeJournal & Archives Current IssueArchivesSubscribeDigital EditionAuthor GuidelinesSubmit an ArticleSend a Letter to the EditorEditorial Advisory BoardAbout Clinical Topics CardiovascularDrugs and DevicesEnd of LifeEndocrineGastrointestinalGenitourinaryHealth and WellnessImmune / Lymphatic SystemsInfection PreventionInfusion TherapyMusculoskeletal / OrthopedicsNeurologyOncologyPain Management / SedationPalliative CarePatient Safety / QualityPharmacologyPsychiatric / Mental HealthPulmonaryRenalTake Note - Practice UpdatesWound / Ostomy Care Practice Settings Acute CareCommunity/ Public / Population HealthCritical Care / Emergency / TraumaGerontologyInformaticsLong-Term Care / RehabilitationMedical / SurgeryPediatricsPerioperativePrimary CareTechnology / EquipmentTransplantationWomen's Health CNEANA Insight Leading the WayPractice MattersInside ANALegal / EthicsMagnet® Resources & Tools Insights BlogSpecial ReportsQuizzes and SurveysVideo Library Mind/Body/SpiritCareer SphereAdvanced Search Legal / Ethics Back to Legal / Ethics Medication errors: Don't let them happen to you March 2010 Vol. 5 No. 3 Author: Pamela Anderson, MS, RN, APN-BC, CCRN A critical care nurse tries to catch up with her morning medications after her patient’s condition changes and he requires several procedures
Study question: What is the current evidence about the factors contributing to medication errors in clinical practice? Study patient given wrong medication data Errors in the medication process: Frequency, type, and potential wrong patient medication errors clinical consequences Lisby, M., Nielsen, L. P., & Mainz, J. (2005). International Journal of
Medication Error Case Report
Quality in Health Care, 17(1), 15-22. This study examined the frequency, type, and consequences of medication errors in stages of the medication process, including https://www.americannursetoday.com/medication-errors-dont-let-them-happen-to-you/ discharge summaries. The researchers gathered data from chart reviews, direct observations, and unannounced control visits. Participants included physicians prescribing medications, nurses dispensing or administering medications, and 64 patients 18 years old or older from a randomly selected medical/surgical department. Of 2,467 opportunities for error, 43% were detected. Over http://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration-1/research/errors.html half of the medication errors were made during transcription, more than 75% of errors were detected in discharge summaries, and 41% were made in the medication-administration stage. Conclusions The researchers concluded that quality-improvement efforts are necessary in almost all stages of the medication-administration process. Automated systems such as physician order entry and barcoding administration of medications may be useful as solutions; because of low error rates in dispensing medications, unit dosing may not be effective in this stage of the process. Study data Characteristics of medication errors made by students during the administration phase: A descriptive study Wolf, Z. R., Hicks, R., & Serembus, J. F. (2006). Journal of Professional Nursing, 22(1), 39-51. This descriptive, retrospective study analyzed data from the U.S. Pharmacopeia MEDMARX database to investigate the characteristics of medication errors made by nursing students from professional nursing programs during the medication-administr
LadyFree28. An Order has been issued by the United States District Court for the District of Minnesota that affects you in the case EAST COAST TEST PREP LLC v. ALLNURSES.COM, INC. Click here for more information ➤ Open letter to the allnurses http://allnurses.com/general-nursing-discussion/medication-error-scenario-668653.html community regarding the Achieve Test Prep Litigation LatestArticlesConferences Nurses › General Discussions › Medication error scenario by Kashia Jan 30, '12 | 7,501 Views | 11 Comments 0 Quick scenario: Pt returning to ltc from acute care with new medication orders. Norco previously ordered number "2" 5/325 q 4 hrs, packages labeled hydrocodone 5/325. New order written: Norco "1" 10/325 TID. 3 different nursing staff was giving "1" 5/325 TID . Nurse that discovered those errors medication error gave "2" of the 5/325 hydrocodone so pt receive the 10 mg of hydrocodone as patient was in severe pain, in middle of night, and left note requesting order needed clarification from Dr. Whose error was this and who should be writing med error documentation? Should the Dr. have written Percocet 1 TID or just hydrocodone 10/325 1 TID? 11 Comments Comment #1 8 Jan 30, '12 by ckh23 Everyone is wrong. I personally think the patient identification errors nurse that discovered the error is more culpable because he/she is actually aware of the error and continued it. Although the patient is getting the 10mg with two tablets, they are also now getting 650mg of Tylenol. The order needs to be clarified and the proper meds need to be obtained. #2 1 Jan 31, '12 by PinkRocksLikeMe I would say since it is YOUR responsibility to do the 5 rights it is every single nurse that gave the wrong dosage. #3 2 Jan 31, '12 by psu_213, BSN, RN Both sides are wrong. The order is for Norco 10/325. The nurses that gave 5/325 didn't give the prescribed dose. Nurses who gave two 5/325 pills gave the correct amount of the narcotic, but twice the prescribed dose of the APAP. Is there even a 10/325 combo of Norco? If not, they would need to give one 5/325 Norco and one 5 mg hydrocodone. I know I have had to do that with oxycodone when 10/325 Percocet was ordered. I really don't see where the clarification for this is needed...it was a pretty simple order that two sets of nurses didn't do correctly. Who should write up the med error? Whomever caught the mistakes. Could be the nurse who made the error, it could be someone who came along later. #4 0 Jan 31, '12 by Nurse