Medication errors are flaws in the healthcare system that can result in injury, disease, and even death. There are ways to prevent these mistakes and to make a facility more safe by enforcing certain rules and regulations. In order for these rules to be effective, the entire healthcare team including doctors, nurses, pharmacy, etc., need to cooperate and work together. It's very common for someone to make a clumsy move which is why triple checking is becoming more and more effective today.
First scenario: A patient was prescribed two completely different medications to her but with similar names. The first drug was hydroxyzine 100 mg PO QID as needed and the second was hydrochlorothiazide 25 mg PO daily. When the nurse was supposed to be giving the 100 mg dose of hydroxyzine they instead pulled four 25 mg hydrochlorothiazide pills from the automated dispensing cabinet. The nurse proceeded to administer the medication before using the barcode scanning system. Not using the barcode was her first mistake. The nurse scanned the barcode after the patient had already consumed the pills. A pop up error came up saying "medication not found" because the daily dose of hydrochlorothiazide had already been given that day. Thankfully, the patient survived this incorrect administration of medication with no side effects to report. The nurse in this scenario administered the wrong medication that ended up being four times the prescribed dose of something that had already been given that day. Although this patient survived this overdose, there are numerous amounts of other medications that could have easily killed this patient within minutes. The nurse made a serious mistake and gave the wrong dose of the wrong medication at the wrong time, putting the patients life in jeopardy. There were many incidences leading up to this error including how similar the two drug names were to each other. A warning on the medication administration record that there was a similar sounding drug for that same patient could have alerted the nurse to the possibility of mixing the two up and prevented the error. The second factor that led to this error was the failure of the nurse to check the medication package against the medication administration record and doctor’s orders. Nurses can prevent most medication errors by utilizing the three checks (and three A's) with labeled medication in hand and the medication administration record in front of them. Good practice is to check the label of the medication three times: when the medication is taken out of the drawer, as the medication is poured or placed in medication cup, and before the medication package is discarded. Had the nurse in this scenario been in the habit of taking his/her time to do three good checks with the medication in hand against the medication administration record the error would have been prevented. The third factor that played a role in this error was the nurse’s failure to correctly use the barcode medication scanning system. The whole reason these barcodes are used is to prevent these exact types of errors that were made so often with paper administration. By waiting to scan the medication until after it was administer defeated the main purpose of the barcode scanner, to make sure the correct medication is being delivered to the correct patient at the correct time and catch mistakes before they happen. While the barcode scanning systems does not replace the careful attention and good judgment of nurses it is another tool at nurses disposal to catch errors before they happen. The system only assists nurses when nurses use it correctly. The final factor that should have made the nurse think twice about administering this incorrect medication was that four pills of hydrochlorothiazide had to be given. There should be a red flag in the nurse’s mind to triple check the order when more than one or two pills must be given for a dose.
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