A prescription was duly entered into the hospital’s Electronic Health Record (EHR) system. The cardiologist verbally relayed the medication change to the head nurse, emphasizing the need for a prompt initiation. However, during medication dispensation, the on-duty nurse misread the prescription in the EHR, juggling multiple patients and tasks. Mistaking ‘metoprolol’ for ‘metformin,’ the nurse prepared the dose for Mrs. Smith. When administering, Mrs. Smith, the meticulous teacher, queried why she was being given medication for diabetes. The nurse reassured her, attributing the medicines to her complex medical regimen.
It was not until the following morning, during the routine medication rounds, that the error was flagged. Another nurse recognized the mistake, leading to an immediate rectification and an apology to Mrs. Smith. While no harm came to Mrs. Smith due to the quick intervention, the incident showed a systemic flaw that needed urgent attention.
Factors Leading to Medication Administration Safety Risk
In the situation of Mrs. Smith, the medication error is evident. It is a stark example of the gaps present in the current healthcare system. The case highlights several challenges. Each challenge can be dissected further into specific contributing factors.
- Similar Drug Names: One of the most common reasons for medication errors is the phonetic and orthographic similarities between drug names. According to the U.S. Food and Drug Administration (FDA), many medication errors have resulted from drug name confusion, and they have documented over 1,400 distinct pairs of drug names involved in mistakes due to their similarities (FDA, 2021). In our case, the confusion between ‘metoprolol’ and ‘metformin’ can be seen as a part of this more significant issue.
- Verbal Communication: Relying verbally with an accompanying written or electronic verification can be safe. The Institute for Safe Medication Practices (ISMP) has listed verbal orders among its “Top Ten Medication Errors and Hazards” (ISMP, 2019). Misheard or misinterpreted words, especially in noisy hospital environments, can lead to errors like the one Mrs. Smith experienced.
Capella 4020 Assessment 1
- Lack of Double Checks: The absence of a systematic double-check mechanism for medication dispensation is a clear gap in patient safety protocols. The Joint Commission has consistently emphasized the need for independent double-checks to prevent high-risk medication errors (The Joint Commission, 2019). Mrs. Smith’s error could have been caught before the administration without a secondary verification.
- EHR Shortcomings: While electronic health records have revolutionized healthcare documentation and communication, they could be more foolproof. The error of not flagging a diabetic medication for a non-diabetic patient highlights a potential area for improvement in the EHR’s safety alert system. According to a study, EHRs have reduced medication errors; they can also introduce new errors, underscoring the need for ongoing system optimization (Upadhyay & Hu, 2022). By examining these factors, healthcare systems can develop more comprehensive strategies to counter medication errors and enhance patient safety.
Evidence-Based and Best Practice Solutions
Medication errors, such as Mrs. Smith’s experience, highlight critical challenges in healthcare. It is vital to address these errors to enhance patient safety. Evidence-based and best-practice solutions offer a roadmap for improvement. Such strategies can be seamlessly integrated into the existing healthcare system.
- Drug Name Clarification: Implementing a system to flag drugs with phonetically or orthographically similar names can dramatically decrease medication errors. The World Health Organization (World Health Organization, 2019) highlights that such a system could significantly reduce medication errors at both the prescribing and dispensing stages. By reducing these errors, healthcare systems can save costs by avoiding unnecessary treatments, hospital readmissions, and potential legal litigations associated with misadministration.
- Electronic Alerts: Fully leveraging the capabilities of Electronic Health Records (EHRs) is pivotal. EHRs, when optimized, can identify and alert healthcare professionals about medications incongruent with a patient’s diagnosed conditions. The Agency for Healthcare Research and Quality (AHRQ, 2019) underscores the importance of meticulous medication management using EHRs. Besides improving patient safety, a robust EHR system can save costs by reducing time-consuming manual checks and the costs associated with correcting medication errors post-administration.
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