Medication Errors in Nursing Homes

This assignment delves into the critical issue of medication errors within nursing home settings. It requires a thorough analysis of scholarly research articles to understand the various factors contributing to these errors, their potential consequences for patients, and strategies employed to mitigate their occurrence. The focus is on examining the complex interplay of human error, system failures, and environmental influences that contribute to medication administration mistakes in this vulnerable population.

Pharmacology for Nursing
Practice
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Table of Contents
Introduction......................................................................................................................................3
Topic 1 Medication error........................................................................................................3
Topic 2: Ethical principle.......................................................................................................4
Topic 3: Legislation................................................................................................................5
Conclusion.......................................................................................................................................6
Reference.........................................................................................................................................7
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Introduction
A medical error is known as the avoidable adverse effect of care whether or not it is
obvious or harmful to the patient. This can include, improper treatment, dispense with wrong
medication injury etc. The present research is based on Coroner Inquest Clinical Case Summary:
“What’s in a Name?”. In the case, Mrs. T was dispensed with wrong medication due to which
her health condition become poorer. The present report will cover medication error and way it
occurs in the case of Mrs. T. Along with this, the significance of drug legislation to nursing will
be explained. Apart from this, the ethical principle will be described with the way it can apply in
clinical practices.
Topic 1 Medication error
As per the given case, Mrs. T was a 74 years old lady who had a past history that
included cholecystectomy, ischaemic heart disease, depression and recurrent urosepsis. She was
admitted to the hospital where she required higher care assistance. In the hospital, her health was
improving but to a medication error, her condition becomes worst. At the time of her transfer
Nurse A, instructed nurse B to dispense her medication before her discharge with respect to
minimise the risk which was missed at the time of transfer (Morton, Fontaine and Gallo, 2017).
However, Nurse B has dispensed the new nitrazepam (Mogadon) 15mg instead of antidepressant
mirtazapine (Avanza) 15mg because of Nurse A mis-read medication chart. Mrs. T was alert but
she was quite prior to her care being handed over the ambulance officers who're responsibility
was to transfer her to the Psychiatric hospital. However, an ambulance officer has noted that her
blood pressure was recording low but he avoids the situation and at the time of arriving hospital
Mrs. T was unresponsiveness. Hence, medication error in the given case was dispensed the new
nitrazepam (Mogadon) 15mg instead of antidepressant mirtazapine (Preshaw, Brazil and Frolic,
2016).
A strategy that can be prevented this error occurring
Double check and even triple check procedures should be followed in the hospital. In this
process whereby another nurse to whom responsibility was transferred must ensure each patient
order is noted and recorded correctly on the physician's order and the medication administration
record (Rafat, Gharib and Rahimi, 2015). Along with this, nurse should read back orders to the
prescribing physicians to make sure that ordered medication was recorded correctly. Hence, this
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process can be carried out from one nurse to the next in which nurse need to read back names of
medication in order to make sure accuracy (Morton, Fontaine, and Gallo, 2017).
The strategy which is identified can prevent the risk of medication error occurring again or
minimise the risk. It is because double check and triple check process helps in making sure that
prescribed medicine is only delivered to the patient. Along with this, similar name error also
avoided with the help of this process. Reading back the prescribing medicine helps in making
sure its accuracy which avoids mistake for dispensing wrong medication.
.
Topic 2: Ethical principle
In nursing, it is essential to follow the ethical principal strictly because it helps in
avoiding the chances of mistakes and improper treatment. In health care one of the most
challenging arenas for ethical consideration is related to deal with medication administration.
There are some rights in medication administration that are as follows to deliver right medication
to right patient instead of providing it to another patient (Mohammadfam, Movafagh and
Bashirian, 2016). Further, medication needs to be provided on time and as a prescribed order
with right doses such as milters, doses or tablet. At last, the nurse should ensure that medication
is dispensed to the patient at a scheduled time.
Ethical principles and way it can be applied provide in clinical practice are as follows
Veracity: Veracity is the principle of truth-telling and its grounded in respect for an
individual and the concept of freedom. In nursing, it is essential to communicate clearly and in
an effective manner for preventing misunderstanding and chances of risk (James, Nelson and
Ashwill, 2014). As per the given case, Nurse B (Registered Nurse) noticed that she had
administered wrong medication to the patient but she did not bring it to Nurse A’s attention as
believing that it may be another name of the same drug. Along with this, Ambulance officer also
noted that condition of Mrs. T was getting worst. They were also concerned about her conscious
state and lethargy.
Non-maleficence: It is known as to do not harm or impose the least harm possible to
reach a beneficial outcome. In nursing harms and its effects can be considered as a part of the
ethical principle. According to this principle, it can be stated that health care providers should do
all the things in order to provide benefit to the patient in each situation (Holloway and Galvin
2016). As per the given case, it is was the responsibility of nurses and ambulance officers to take
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a step in a situation when Mrs. T condition became worse so that health issues can be overcome.
But both of them had not avoided the harm that makes patient suffer from death (van Hoof,
Verboor, Oude Weernink and van Zaalen, 2018).
These ethical principles are not upheld by nurses in the provided case as it is clearly
mentioned that nurse A has misread the medication chart and nurse B noticed discrepancy but
she avoided it instead of making clear with the nurse (Hayes, Jackson and Power, 2015). En
route, however, the ambulance officers became worried as her blood pressure was recording
‘low’ which initially responded to position changes but then dropped again. Hence, unethical
practice of Nurses leads to negatively impact the health of Mrs. T.
Topic 3: Legislation
Importance of drug legislation in nursing is that it helps in providing all the medication
time to patients. Through following legislation, it will become easy for the nurses to avoid any
type of medication error or causes of improper treatment. Hence, legislation also help in making
aware to avoid and illegal activity which can harm patients.
Australian schedules for medicines and poisons listed below
Schedule 2: Pharmacy medicine:
Under this, all the medicine is safe and can be prescribed by health care professionals.
This is basically used for minor symptoms which can easily recognised and do not need medical
diagnosis (Elliott, Lee, and Goeman, 2016).
Schedule 3: Pharmacist only medicine:
These are drugs and poisons otherwise known as pharmacy medicine which are mostly
prepared for therapeutic use. The are safe in use but advice of health care professional is required
in it.
Schedule 4: Prescription only medicine:
Schedule 4 drugs and poisons are required proper monitoring while prescribing these
medicines. Along with this, it can be only prescribed by an authorised prescriber.
Schedule 8: Controlled drug:
According to the schedulse 8, the standard for uniform scheduling of medicine and
poisons are strictly regulated because of the high chances of misuse or physical depended
associated with them. Therefore, it is important prescribed them, dispenses or destroyed in such
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particular manner that is in compliance with all the stated and as per different drugs regulations.
The use if this medication without any authority is crimes.
The generic name of Panadol Osteo is Osteomol tablet and it is considered in schedule 2 for
medicines and poisons (Amster, Marquard and Fisher, 2015). Further generic name of Endone
tablet is Oxycodone hydrochloride and it is considered under the schedule 4. There are two
medications which are involved in medication error in the given case that are nitrazepam and
mirtazapine. These both medications are belonging to schedule 4. In respect to using medication
of schedule 4 nurses required proper monitoring, safety, and efficacy. However, in the provided
case nurse B has dispensed mirtazapine to Mrs. T which is wrong medicine and she also not
properly monitored her after providing medicine. It is the responsibility of nurse before using
medicine belong to schedule 4 to take proper steps which are ignored by them.
Conclusion
From the above report it is concluded that in health and social care, nurses play
significant role in respect to deliver quality services to patient. Their role is to provide
medication on time and other care in order to overcome their health issues. Further it is
concluded that medication error can directly impact the health of services user. Therefore, nurses
should be ensuring before providing any type of medication to the patients. Through following
the ethical principle different types of risk can be avoided by the nurses while providing care to
patients.
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Reference
Amster, B., Marquard, J., Henneman, E. and Fisher, D., 2015. Using an eye tracker during
medication administration to identify gaps in nursing students’ contextual knowledge: An
observational study. Nurse educator, 40(2), pp.83-86.
Elliott, R.A., Lee, C.Y., Beanland, C., Vakil, K. and Goeman, D., 2016. Medicines management,
medication errors and adverse medication events in older people referred to a community
nursing service: a retrospective observational study. Drugs-real world outcomes, 3(1),
pp.13-24.
Hayes, C., Jackson, D., Davidson, P.M. and Power, T., 2015. Medication errors in hospitals: a
literature review of disruptions to nursing practice during medication
administration. Journal of clinical nursing, 24(21-22), pp.3063-3076.
Holloway, I. and Galvin, K., 2016. Qualitative research in nursing and healthcare. John Wiley
& Sons.
James, S.R., Nelson, K. and Ashwill, J., 2014. Nursing care of children-E-book: principles and
practice. Elsevier Health Sciences.
Mohammadfam, I., Movafagh, M. and Bashirian, S., 2016. Comparison of Standardized Plant
Analysis Risk Human Reliaşbility Analysis (SPAR-H) and Cognitive Reliability Error
Analysis Methşods (CREAM) in Quantifying Human Error in Nursing Pracştice. Iranian
journal of public health, 45(3), pp.401-402.
Morton, P.G., Fontaine, D., Hudak, C.M. and Gallo, B.M., 2017. Critical care nursing: a holistic
approach (p. 1056). Lippincott Williams & Wilkins.
Preshaw, D.H., Brazil, K., McLaughlin, D. and Frolic, A., 2016. Ethical issues experienced by
healthcare workers in nursing homes: Literature review. Nursing ethics, 23(5), pp.490-506.
Rafat, S., Gharib, A. and Rahimi, F., 2015. Related factors in medication error based on nurses'
self-report in Sanandaj, Iran. Der pharmacia lettre, 7(10), pp.198-201.
van Hoof, J., Verboor, J., Oude Weernink, C.E., Sponselee, A.A.G., Sturm, J.A., Kazak, J.K.,
Govers, G.M.J. and van Zaalen, Y., 2018. Real-Time Location Systems for Asset
Management in Nursing Homes: An Explorative Study of Ethical
Aspects. Information, 9(4), p.80.
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