Abstract
Medication errors are still experienced in clinical settings in spite of the current technological advancements. Nurses play a crucial role in the provision of care including medical therapy to patients. In line with this, they ought to be trained on how to avoid medication errors. In this paper, a case scenario in which a nurse administers wrong vaccines to two patients with similar names is assessed. In addition, it gives strategies that can be used to prevent the occurrence of such a medication error. Nursing leadership, minimization of communication barriers between patients and nurses, a decent duty delegation process and the championship of patients’ rights are the keys to addressing medication errors.
Introduction
In spite of technological advancements, medication errors still occur in a clinical setting (Le Grognec et al., 2005). However, in order to address this challenge, it is paramount to have decent leadership. Nurses are at the core of care delivery, and it is paramount that they are guided on how to administer care safely and effectively (Cousinns et al., 2005). In line with this, it is paramount to have informed leadership. This will ensure the formation of decent protocols and policies that will help in the minimization of medication errors.
One of the common medication error is the confusion of therapy/medication between two or more patients with similar or almost similar names. In this case study, two patients with similar names: 1) Lee Siew Mei 2) Lee Siew Mee have to be given vaccinations. Mei ought to receive Hep B Booster and her counterpart has to be given HPV injection. Without well-defined patient identifiers of name and IC or address, and the absence of a senior staff nurse guidance, a nurse on duty, gave the two patients the wrong vaccination. Instead of Mei getting Hep B Booster, she was given HPV injection. Her counterpart got Hep B Booster instead of HPV injection. This error led serious medical complications in the affected patients because of following their body’s reaction to the wrong medications. Nursing leadership is key to addressing such a medication error.
Background information
Aronson (2009) defines a medication error as a failure in the treatment process that contributes to, or can harm the patient. These errors can be classified as knowledge-based mistakes, action-based slips, rule-based slips, and memory-based slips. In order to design effective preventative strategies, it is essential to understand the initial cause (Anselmi, Peduzzi & Santos, 2007).
In this scenario, the cause of this error is as a result of poor patient file classification. In other words, the hospital does not have a conclusive patient identification module. Therefore, nurses often confuse the diagnoses and medications of patients with similar names. It is paramount to construct a simple and well-defined client classification process if this problem has to be addressed.
Institutions with few medical errors that are caused by this factor use different client classification tools. The patient is often given a unique number that identifies them. There are different medical data software that help in the classification process. Patients care first be identified by their unique patient number. When the customer number is assessed, it should provide the demographic, ethnic and social factors and physical even locations. In addition, prescriptions must have a unique customer ID number. This will help reduce the errors that stem from common or similar patient names.
My approach: Prevention and Improvement
Nursing leaders play an essential role in the provision of safe and effective medications. In order to attain this goal, it is paramount to have engineer strategies that will help in minimizing medication errors (Haw, Dickens & Stubbs, 2005).
First, it vital to use a computerized system. Since there are so many clients visiting the hospital, it is prudent to capture data electronically. All nurses in the nursing department ought to be trained on how to differentiate clients using their unique client ID. In this case, no client can be given the wrong medication or therapy.
Secondly, it will be prudent to improve work delegation process. The nurse in charge of the nursing department must engineer a decent duty roster that does not impose fatigue on nurses. Numerous studies have shown that burnout and fatigue are some of the major causes of errors in nursing and medical practice (Cimiotti et al., 2012; Manojlovich et al., 2011). One of the most effective work schedules in the nursing department is that which allows nurses to work in rounds. A group of nurses are assigned the duty of manning different locations or patients or roles at a specified period, usually short enough to limit the burnout. At the expiry of their period, they normally take a rest while their colleagues assume duty.
Thirdly, it is important to address the communication barriers that could arise between nurses and patients. In this case, care will be taken in the hiring process to ensure that nurses with multilingual skills are hired. In addition, those that have been hired already will be sponsored to study short courses that will double their language prowess. This step will ensure that the nursing department has nurses that can speak at least two different languages. At times, due to miscommunication nurses and patients can misunderstand each other. For example, during the registration of patients, nurses could misspell names if they are not sure about the pronunciation of a specific item. At the point of care, the nurse may fail to understand the patient because of the language barrier and this can distort the provision of therapy. Therefore, investment in multilingual nurses is key to addressing the communication barrier between patients and nurses (Anoosheh et al., 2009; Chapman, 2009; Patak et al., 2009).
Fourthly, it will be essential to implementing decent policies that safeguard the rights of patients: timely care, right to choose the route of administration, and right to accurate dose and dosage. The goal of nursing is to restore health by caring for patients. This goal is attained by administering among other things evidence-based medications. In line with this, it will be prudent to educate the nurses on the importance of safeguarding patients’ health, and the consequences associated with unethical, unprofessional practices and negligence. In this case, nurses will be educated on the patients’ rights such as the right to access medical care or therapy in a timely manner. Patients also have the right to decent dosage and doses, as well as well-thought route of administration.
In addition, it will be helpful to have an assessment protocol that will help in the review of this approach. In other words, the progress of this intervention and improvement plan will be measured on an on-going basis in order to identify the challenge within it. A reduction in medication errors will be an indication that the process is effective.
In conclusion, this paper has shown that medication errors are still a big challenge in nursing and medical practice as a whole. In order to address this challenge, it is paramount to have decent leadership. Nurses are at the core of care delivery, and it is paramount that they are guided on how to administer care safely and effectively. This paper has highlighted an example of a medication error in which the nurse administered wrong vaccinations because of an error in patient name labelling. This paper has emphasized the importance of nursing leadership. On top of that, it is vital to computerize the patient classification process, and implement decent policies that safeguard the rights of patients. Moreover, this challenge can be addressed by improving work delegation process and eliminating communication barriers between patients and nurses.
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