Medication errors have significantly affected patient safety, as some have led to mortality or disability. Despite significant improvements by our health system to mitigate these errors, medication safety is still a concern due to various causes.
The Food and Drug Administration (FDA) defines a medication error as an event capable of causing inappropriate medication use or patient harm in the hand of the prescriber, administering clinician, patient, or consumer of the medication (Center for Drug Evaluation & Research, 2019).
In the FDA’s definition, medication errors are preventable. The purpose of this paper is to describe a situation where a medication error occurred, explain the specific risks for the patient, and describe the best nursing coordination strategies to improve patient safety.
Charlie is a 22-year-old white male who had an emergency appendectomy following acute appendicitis. His pain persisted even on day four after the resumption of oral intake, and his surgeon prescribed oral morphine medication 10 mg start dose that evening. RN, the oncoming nurse that evening, administered 10 milliliters of morphine solution for injection infusion because the patient had been on other intravenous infusions in the postoperative period.
The formulation given contained a 10mg/ml solution. Three hours about half an hour minutes after the administration of this solution, Charlie started vomiting the milk he had taken that evening and appeared to be in respiratory distress. Therefore, RN called Charlie’s surgeon to review him.
Various patient safety risks could have led to this patient’s risk for medication errors. These errors relate to healthcare professional practice, products, procedures, and systems. These errors can be traced back to product labeling, packaging, prescription, administration, and monitoring.
These patient-safety risks related to medication administration include but are not limited to inadequate or unclear instructions, illegible writing, lack of medication reconciliation, improper administration documentation (Rosenthal & Burchum, 2020), inappropriate drug selection during administration, and failure to continue or discontinue medications. More than one risk can contribute to a single occurrence of medication error due to medication administration.
A qualitative study by Schroers et al. (2020) classified these patient safety risk factors in medication administration into personal factors and contextual factors. Personal factors include fatigue and complacency, while contextual factors include interruptions (Rosenthal & Burchum, 2020), night shift duty, unavailability of administration guidelines (Wondmieneh et al., 2020), and heavy nurse workloads. According to Rosenthal & Burchum (2020), about 60% of these medication errors occur during the care transition. Personal and contextual factors come into play at this time.
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