1. State how this adverse event could have been prevented.
Adherence to protocols, policies and standards regarding medication administration prevents medication errors (Breeding et al., 2013). Prior to administering any medication, the six rights of medication administration must be fulfilled: right drug, right dose, right route, right time, right patient and right documentation. Upon procurement of the medication, drug label information must be compared with the prescription on the chart to ensure that they match. Visual comparison prevents errors from drugs that sound and look the same. To avoid confusion, studies show that it is best to check the drug’s generic rather than trade name (Perry & Potter, 2010). Relying on packaging and appearance is an unsafe practice. It is also advisable to perform the three checks to ensure the right drug (Drach-Zahavy et al., 2013).
Another piece of information that needs cross-checking between the prescription and the medication label is the right dose. When taking out medications, it is unsafe to assume that they are the correct medications and dose because technicians who refill the cabinets and carts are human and can make mistakes (Breeding et al., 2013). Matching should always be done. Nurses should also recognize that physicians who write prescriptions can also make mistakes. To guard against potential harm to the patient, it is necessary to check the drug literature for minimum and maximum doses per weight, age, vital signs, lab results and other variables (Jones, 2009, Perry & Potter, 2010). If there is any question with regard to the dose, such as when it falls above or below the usual range and when handwriting is illegible, it should be clarified with the prescribing physician.
In addition, the dose last given and the time it was administered should be reviewed to make sure giving the next dose will not lead to overdosing. When preparing the medication, there should be no distractions, disruptions and time pressures to enable the nurse to focus on the task (Odom-Forren, 2010). Moreover, the right measuring tool and correct use of the tool must be used during preparation. In addition, the drug expiration date has to be checked to make sure it is still as potent as the strength written on its label. Double checking the medication with a fellow nurse should not be done in a ritualistic fashion but should help identify errors (Drach-Zahavy et al., 2013).
Refer also to the prescription when considering the right route and right time. If there is missing information, clarification is needed from the physician before administration (Grigg, Garrett & Craig, 2011). The right time prevents over- and underdosing especially when therapeutic serum drug levels need to be maintained. If dosing times are indicated by confusing abbreviations, it should be questioned (Perry & Potter, 2010). The time of the last administration must be noted to see if there is a need to adjust as a result of delayed giving of the drug to prevent overdosing. The nurse must make sure to give the drug to the right patient. The information on the identification bracelet must again be compared to the prescription. Since there is a possibility of two patients having the same name, the birthdate is another crucial piece of information that must be matched (Jones, 2009). The intervention should be documented promptly to communicate that it was done and when.
2. Identify and discuss the relevant Australian Nursing and Midwifery Accreditation Council (ANMC) competency standards that are breached in this case.
Nurses are bound professionally to fulfil the duty of care due through performance conforms to established practice standards and the responsibility to keep patients from harm (ANMC, 2006). There are facility guidelines and protocols governing medication administration and laws relating to negligence as a result of medication errors which nurses are expected to be aware of and comply with. In administering the incorrect dose, the nurse is just as accountable as the physician (Bucknall, 2010). Complacency on the part of nurses contributes to error. Nurses are also expected to practice within the framework of professional and ethical nursing by utilising nursing knowledge and skills to ensure provision of care that is effective and safe (ANMC, 2006). However, there was failure to determine the appropriateness of the dose and thus failure to question or clarify the high dose. If nurses do not regard it as their duty to serve as check and balance for prescribed medications, patient safety is compromised.
Further, it is also the responsibility of the nurse to provide comprehensive, effective, safe and evidence-based care (ANMC, 2006). There are guidelines and practices advocated in literature regarding increasing the safety of medication administration. It is a professional responsibility of nurses to ensure their level of knowledge and skills are adequate in meeting expected performance based on standards (Drach-Zahavy et al., 2013). Poor knowledge of the medication led to the administration of the inappropriate dose yet drug information are available resources. Nurses are also expected to facilitate a physical, cultural, psychosocial and spiritual environment promoting security and safety (ANMC, 2006). Again, this requires knowledge and application of principles pertinent to the safe administration of medications.
3. As a Registered Nurse, prior to administering any medication, what key information related to the pharmacology of the medication should you have a comprehensive knowledge of?
In administering a medication, knowledge of the indications, usual doses, therapeutic effects, side effects, adverse effects, interactions and contraindications related to the drug should be known (Murphy & While, 2012). Indications are the medical conditions, signs and symptoms that the drug is supposed to treat or manage. Meanwhile, the usual doses commonly relate to severity of the condition, routes and frequency of administration, age and weight. Indications and dose inform the nurse about the appropriateness of the prescribed drug and its dose (Bullock & Manias, 2011). The therapeutic effect relates to what the drug intends to do in relation to the patient’s condition. If it can be ascertained through nursing assessment that the patient is not exhibiting the desired effects of the drug, this serves as basis for informing the physician before giving the drug. For PRN medications, it also indicates whether or not to continue administration.
Knowing the side effects of the drug informs the nurse whether signs and symptoms noted are related to the drug and require management but are not reasons preventing administration (Bullock & Manias, 2011). On the other hand, adverse effects are serious and often life-threatening effects of the drug necessitating immediate intervention including stopping drug administration, administering an antidote and calling the physician (Murphy & While, 2012). Part of the nursing responsibilities of administering a drug is to monitor for these effects and respond in a timely manner to prevent serious complications and death. Contraindications are factors or patient conditions that are legitimate reasons why the drug should not be given (Murphy & While, 2012). These include previously unknown allergic reactions and the use of other drugs. Lastly, interactions refer to other drugs and lifestyles that can either reduce or increase the potency of the drug.
4. What are the main points you will cover in the report? What resources or support services can you identify to assist you in this situation?
The report is a comprehensive, factual and accurate description of the event which will be used by the Route Cause Analysis (RCA) team to determine what components of the system contributed to the medication error (Ashurst, 2007). The analysis will serve as springboard for improvements to prevent future occurrences of the error. What the RCA needs to know include patient identification, the date and time when the incident occurred, the nurse who administered the medication as well as the nurses who might have served to double check the prescription against the medication label. The nurse then needs to detail the events preceding the error. The medication administration process will be broken down into the individual steps taken starting from reading the prescription and pulling the medication until documentation and monitoring.
Subsequently, the nurse includes in the report where and at what time the adverse event or overdose took place or was discovered (Hynes, 2009). A description of the patient’s condition when found at the time of the medication and observation round is written down. How the nurse responded to the situation also has to be reported along with all the actions taken to correct the situation (Ashurst, 2007). The accounts of other witnesses such as fellow nurses or members of the patient’s family must be documented as well. The report should not be judgmental or focused on who are liable for the error. Rather, it is meant to foster openness about errors in order for everyone to learn from it (Ashurst, 2007). It is important to be familiar with the protocols regarding the writing of incident reports and to use the appropriate forms or templates. The unit manager can also be approached for assistance in writing the report.
References
Ashurst, A. (2007). Writing an accident or incident report. Nursing and Residential Care, 9(8), 381-383.
Australian Nursing and Midwifery Accreditation Council (2006). National competency standards for the registered nurse. Retrieved from www.nursingmidwiferyboard.gov.au/documents/default.aspx?
Breeding, J., Welch, S., Whittam, S., Buscher, H., Burrows, F., Frost, C., Wong, A. (2013). Medication error minimization scheme (MEMS) in an adult tertiary intensive care unit (ICU) 2009-2011. Australian Critical Care, 26(1), 58-75.
Bucknall, T.K. (2010). Medical error and decision-making: Learning from the past and present in intensive care. Australian Critical Care, 23(1), 150-156.
Bullock, S., & Manias, E. (2011). Fundamentals of pharmacology. (6th ed.). Sydney: Pearson Education Australia.
Drach-Zahavy, A., Somech, A., Admi, H., Peterfreund, I., Peker, H., & Priente, O. (2013). How do we learn from errors? A prospective study of the link between the ward’s learning practices and medication administration errors. International Journal of Nursing Studies, article in press.
Grigg, S.J., Garrett, S.K., & Craig, J.B. (2011). A process centered analysis of medication administration: Identifying current methods and potential for improvement. International Journal of Industrial Ergonomics, 41(1), 380-388.
Hynes, J. (2009). Don’t be intimidated by incident reports. LPN2009, 5(2), 4-5.
Jones, S.W. (2009). Reducing medication administration errors in nursing practice. Nursing Standard, 23(50), 40-46.
Murphy, M., & While, A. (2012). Medication administration practices among children’s nurses: A survey. British Journal of Nursing, 21(15), 928-933.
Odom-Forren, J. (2010). Medication administration and errors. Journal of PeriAnesthesia Nursing, 25(3), 206-207.
Perry, A.G., & Potter, P.A. (2010). Clinical nursing skills and techniques. (7th ed.). Missouri: Elsevier.
