C33 Nursing

Introduction:

Administering and prescribing restricted medication is a delicate issue. While the right medications improve an individual’s mental, physical, emotional and well-being, drugs that are powerful can pose some serious danger to the patient (PSA Advisories, 2016). When a healthcare provider administers too little or too much or even administers the wrong medication, the effects are devastating. In this research, we shall take a look at a serious medication error that happened in Canada, what effects the error had, how can the state do to prevent these mistakes and also how the health care providers can do to prevent the errors from happening again, but if they to occur again, what will the care provider do differently to respond to it.

This medical error case involved a four-year-old who was admitted in Broadview Union Hospital in Saskatchewan, Canada, on May 14^th, 2015, with severe Attention Deficit Hyperactivity Disorder, where a nurse-administered a wrong dose instead of the one Adam’s doctor had prescribed to him (Neinstein, 2016). The doctor had prescribed a 0.3 ml liquid dose to treat the boy’s ADHD, the nurse-administered a 3 ml dose. 30 minutes after the boy was given the first dosage, he started to act like a slobbering drunk where he couldn’t even stand up as he was drooling to a point where he had to be carried because he couldn’t walk on his own. The overdose went unnoticed for months until the boy’s parents decided to report the son’s reaction to the family doctor and also to get a second opinion at a local clinic. But eventually, the overdose was discovered after a second visit to the doctor and was immediately corrected. But to make sure that there was no permanent damage to the boy’s liver and kidney, he was supposed to be checked by a doctor over a period of five years.

The factor that led to this error is a dispensing error the wrong dose was administered to the wrong patient by the nurse as the doctor had prescribed the correct dose to the boy. Medication errors can cause severe physical injury or even death at times, to the patients, these preventable mistakes can also severe psychological, emotional, and financial stress to the family and loved ones as well as the health care providers and the entire health system as a whole (PSA Advisories, 2015). In this case, it caused Adam a lot of pain to the point where he was not able to walk and even could have led to a new condition by damaging his kidney or his liver. Also, to the boy’s family, it caused them a lot of stress trying to figure out Adam’s new condition they even had to carry him given that he walked on his own before.

The nurse who inadvertently gave Adam the wrong dose suffered from guilt, shame and self-doubt in a condition known as the “the second victim” where its effects can be life-threatening as some health care providers can even commit suicide (PSA Advisories, 2016). And the fact that Adam’s family pursued person injury lawsuit against the nurse for negligence, it will affect his career advancement and also revoking of his silence. The health care system will spend a lot of money investigating and modifying policies trying to ensure that such errors do happen again. Cumulative errors affect the reputation and the re-accreditation of the entire health system in Canada.

There is no mandatory medical errors disclosure to a public body and also no national relevant system to monitor how an error like this happens which makes it difficult for the regulatory bodies to take action on care providers who commit medical errors. This is one of the political factors that influence medication errors (ISMP Alerts, 2018). Other factors that contributed to this medication error are the decreasing sense of commitment, inadequate attention to details because the nurse ought to have noticed the error in the first place. Other factors could have been tiredness, confusion, and stress from the care provider. Some economic factors that led to the error include; lack of skilled and competent healthcare providers, and long work days clearly influenced this error (ISMP Alerts, 2018). The state should ensure that healthcare providers employed by the government are highly competent for the job. This is the first step to preventing much more serious medical errors from happening in the future.

The hospital’s response was systemic as it involved examining Adam to make sure that the error hadn’t caused any damage to his organs. It also involved shifting from the post-accident analysis toward designing certain care processes that will help in detecting any more errors (PSA Advisories, 2017). The national agencies are to hold the nurse accountable for his action by shifting from blame to punishment to learning how to fix systemic problems through standardization and simplification procedures and to also reduce over-reliance of the memory. The national safety organization is addressing this error and many others by employing strategies that help healthcare providers in primary care to improve patient safety by reducing medication errors (Quarterwatch Reports, 2018). These strategies include using computer technology, employing clinical nurses and also through educational programs. These organizations have introduced a process of documenting and establishing a definitive, consistent list of medications across care transitions and then rectifying any discrepancies that they come across.

Nurse’s concern about damaging the relationship with the patients is a factor and a major barrier to the medical error responses. Also, the state is concerned with the damage medical errors will cause to the entire health system, hence the fear of disclosure. It might also lower the cost of health which impacts the country’s economy. In order to improve the patients’ safety and care, the hospital environments should promote communications in all the levels as supporting care providers (ISMP Alerts, 2018). They should encourage questions on issues concerning patients’ safety and should also be allowed to report any medical errors without putting too much blame on the care providers. This would enhance the value of education in medical residents’ training and also, giving them the opportunity to learn from their colleagues which will improve quality of care, continuously, through cooperative teamwork (PSA Advisories, 2015). Even though this does not apply to the medical residents only, it focuses attention to them which may be a good place to introduce the required change of culture so as to shift the team’s mentality or the shared accountability and responsibility in healthcare settings.

One of the leadership skills the health care provider should have is by being patient-centered where he ensures successful patient outcomes through promoting greater nursing expertise towards the patient. This leadership reduces medical error rates as the care provider administers the prescribed dose with caution which in turn reduces rates of error deaths. This is due to the fact that, effective leadership ensures successful clinical outcomes by reducing medication error rates (PSA Advisories, 2018). If a medical error happens, this time the care provider should report the error and also giving full explanations to the patients and the families. The healthcare provider should confront this issue with openness and honesty which will be critical to building a healthy culture that will encourage continual clinical improvement.

In conclusion, medication errors are preventable and all the health care providers should ensure a tremendous decline in these errors if they observe the stated role carefully. But in order to achieve this, strict legislative measures should be put in place to ensure that these measures are effectively adhered to.

References:

PSA Advisories (2015, September 16). Medication Errors Affecting Pediatric Patients: Unique Challenges for This Special Population. Retrieved from https://www.ismp.org/alerts/medication-errors-affecting-pediatric-patients-unique-challenges-special-population

PSA Advisories. (2015, December 16). Medication Errors Involving Overrides of Healthcare Technology. Retrieved from https://www.ismp.org/alerts/medication-errors-involving-overrides-healthcare-technology

PSA Advisories. (2016, March 15). Medication Errors Involving Healthcare Students. Retrieved from https://www.ismp.org/alerts/medication-errors-involving-healthcare-students

PSA Advisories. (2016, March 27). Oral Anticoagulants: A Review of Common Errors and Risk Reduction Strategies. Retrieved from https://www.ismp.org/alerts/oral-anticoagulants-review-common-errors-and-risk-reduction-strategies

PSA Advisories. (2016, September 21). Prescribing Errors that Cause Harm. Retrieved from https://www.ismp.org/alerts/prescribing-errors-cause-harm

Neinstein, G. (2016, November 22). Medication errors are common across Canada – how should the healthcare system respond? Retrieved from https://www.medicalmalpractice.ca/medication-errors-are-common-across-canada-how-should-the-healthcare-system-respond/

PSA Advisories. (2017, March 15). Medication Errors Attributed to Health Information Technology. Retrieved from https://www.ismp.org/alerts/medication-errors-attributed-health-information-technology

PSA Advisories. (2017, December 20). Medication Errors in Outpatient Hematology and Oncology Clinics. Retrieved from https://www.ismp.org/alerts/medication-errors-outpatient-hematology-and-oncology-clinics

ISMP Alerts. (2018, March 24). Cyclosporine Dispensing Errors. Retrieved from https://www.ismp.org/alerts/cyclosporine-dispensing-errors

ISMP Alerts, I. (2018, April 23). Packaging Could Lead to Acetaminophen Overdoses. Retrieved from https://www.ismp.org/alerts/misleading-packaging-could-lead-acetaminophen-overdoses

Quarterwatch reports, (2018, September). Annual Report: Four Feared Adverse Events. Retrieved from https://www.ismp.org/quarterwatchtm/annual-report-Sept-2018

ISMP Alerts, (2018, September 6). Check for Proper Nucala Dose Preparation. Retrieved from https://www.ismp.org/alerts/check-proper-nucala-dose-preparation

PSA Advisories. (2018, September 20). The Breakup: Errors when Altering Oral Solid Dosage Forms. Retrieved from https://www.ismp.org/alerts/breakup-errors-when-altering-oral-solid-dosage-forms