Introduction
Medication errors plague healthcare systems worldwide and must be addressed promptly. Patients’ safety and well-being may be jeopardized as a result of these mistakes. To effectively avoid pharmaceutical mistakes, it is crucial to understand their causes. In this paper, I will describe a case of a pharmaceutical error that came to my attention during my professional career and then do a root cause analysis (RCA) to determine what led to the mistake. All identifying information has been changed to protect the privacy of those involved in the occurrence used as an example.
Medication Error Issue
Ms. Smith, a woman brought to the hospital with a severe respiratory illness, was the victim of a drug mistake. Amoxicillin, an antibiotic given by the attending physician, is to be taken orally every 8 hours. Unfortunately, the patient’s documentation did not accurately reflect the drug administration schedule because of a misunderstanding between the medical team and the nursing staff.
During one shift change, the new nurse failed to realize that the antibiotic was supposed to be given every 8 hours and instead gave it every 12 hours. As a result, the patient’s illness persisted for an extended period of time, and their hospital stay was extended since the full therapeutic effects of the medicine were not realized.
Root Cause Analysis
This prescription mistake was investigated using a Root Cause Analysis to determine its essence. A failure in communication between the medical team and the nursing staff was recognized as a key underlying cause. The nursing staff assumed they understood the doctor’s instructions, so they didn’t request clarification when the doctor did not explicitly outline the drug regimen. Medications were not adequately documented or transferred between shifts since there were no established protocols for doing so. Inconsistency and muddled thinking resulted from a lack of standardization in the documentation of medicine delivery regimens.
The nurse who made the mistake had worked many shifts in a row, which led to exhaustion and a decrease in her mental capacity. Their ability to double-check the drug regimen may have been hindered by the large volume of work they had to accomplish (Assiri et al., 2019). Because she lacked appropriate training, the offending nurse made a mistake when entering a medication order into the hospital’s electronic health record (EHR) system. A possible cause of the incorrect reading of the prescription is a lack of familiarity with the system. Not having a second nurse check the dosing plan before each medicine delivery was a significant flaw. To prevent mistakes from reaching the patient, it is common practice to perform a double check (Rutledge et al., 2018).
Conclusion
Patient safety in healthcare settings is hampered by medication mistakes, as mentioned. This episode highlights the importance of investigating and addressing the underlying issues that lead to such mistakes. Medication mistakes can be significantly reduced by implementing effective preventive techniques, such as improved communication, standardized processes, workload management, and comprehensive training. A culture of safety, in which all team members are encouraged to report problems without fear of retaliation, should be a top priority for healthcare companies. Reporting incidents and gaining knowledge from near-miss experiences helps enhance the system.
Although I work in the medical field, I was not involved in the pharmaceutical mix-up described in this essay. Instead, I learned about it during a hospital quality improvement team debriefing. The episode has stuck with me and reinforced the importance of being vigilant, maintaining open lines of communication, and dedicating oneself to patient safety. The healthcare sector as a whole can learn from these types of accidents and improve patient care by working together to eliminate medication errors.
References
Assiri, G. A., Shebl, N. A., Mahmoud, M. A., Aloudah, N., Grant, E., Aldjadhey, H., & Sheikh, A. (2019). What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open.
Rutledge, D. N., Retrosi, T., & Ostrowski, G. (2018). Barriers to medication error reporting among hospital nurses. Journal of Clinical Nursing, 27(9–10), 1941–1949.