Medication errors are the most common type of medical errors. As per article “Reducing Medication Errors Using LSS Methodology: A Systematic Literature Review and Key Findings”, medication error is one the primary leading causes to the patient morbidity and mortality. Medication error can occur at every stage- medication delivery, prescribing, transcribing, dispensing and administration. The article states medication error can be preventable and that it is in the control of the healthcare professionals and patients (Trakulsunti, et al., 2020). In their book Quality and Safety in Nursing, Sherwood and Barnsteiner write that according to the World Health Organization, the rate of medication errors is estimated to occur in 10-20% of medication errors and that nurses can take the responsibility for improving the patient’s safety (Sherwood & Barnsteiner, 2021).
My recent nursing experiences include working as a home health nurse and as an urgent care nursing in an ambulatory setting. In home health care, medication errors usually occur at the administration stage. After being discharged home from the hospital, patients do not always understand the changes made to their medication regimen. For example, changes were made to their diuretic medication or new parameters were prescribed for their diuretic. The patients, for instance, do not understand to take an extra tablet of Lasix if there is a weight gain of 2 pounds or more or if there is an increase in edema. I have experienced that elderly patient, especially the ones without family support or without a caregiver, have issues with remembering instructions given to them on their discharge day from the hospital. Therefore, in our home health care, we have made every attempt possible to visit recently discharged patients within 24 to 48 hours to assess the patients and review the medication regimen. In addition, we always provide the patients a new list of their medications and compare each medication on the list with the actual mediation bottles in their home.
To reduce medication errors, in our urgent care, after confirming patient’s identity, we scan the medication prior to administering it. This is to ensure that we are giving the right medication with the correct strength and dose to the right patient. The computer would flag us if we scanned the wrong medication, wrong strength, or dose. However, this step is to prevent medication error when medication is administered by the nurses. Medication errors can still be made by the patients after leaving the urgent care. What I think could be done in addition to this workflow to prevent medication errors is to provide patients a list of their medication regimen and providers or nurses to thoroughly review any new medications or any changes made to medications reflecting the care provided at urgent care. Spending some time with the patients to review medications, to assess for their understanding and knowledge and to correct any discrepancies is one way to reduce any potential medication errors. Although I feel this is the best practice that should be done at every visit with every patient as it allows the patients in the decision-making process of their care, involves the patients to take responsibility and allows the patients ask questions or address any concerns, it is not always ideal as it is very time-consuming, and we don’t always have the staff or the resources to do so.
References
Trakulsunti, Y., Antony, J., Ghadge, A., and Gupta, S. (2020). Reducing medication errors using LSS methodology: a systematic literature review and key findings. Total Quality Management, 31(5-6), 550-568. https://doi.org/10.1080/14783363.2018.1434771
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