Administering Anticoagulants: A Case Study

Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.

In Australian hospitals medication administration errors make up 9% or 1 in10 of all medication administrations. These errors include wrong doses, wrong intravenous infusion rates and errors made by prescribing doctors. Errors on discharge of patients were increasingly higher with up to 2 errors per patient related to doctors transcribing discharge medications (Roughead, Semple, & Rosenfeld, 2016).

According to the Food and Drug Administration (FDA 2009), the wrong route of administrating medication accounts for 1.3 million injuries each year. An article published in September issue of the Journal of Patient Safety estimates there are between 210,000 and 400,000 deaths per year associated with medical errors. This makes medical errors the third leading cause of deaths in the United States, behind that comes heart disease and cancer. To prevent medical errors always follow the Three Checks and most importantly the Rights of Medication Administration. The “Rights of Medication Administration” helps to ensure accuracy when administering medication to a patient. When administering medication the administer should ensure they have the Right Medication, Right Patient, Right Dosage, Right Route, Right Time, Right Route, Right Reason, and Right Documentation. Also remember the patient has the right to refuse, assess patient for pain, and always assess the patient for signs of effects.

Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of

They showed a two vials that were very much alike,one is heparin and the other one is hep-lock up.Since that accident happened to Dennis Quaid’s twins the labeling of vial has been changed.And then there is Steve Rel who has a son died after taking a pain medicine and it went months and months without any answers from the medical examiner what really happened to their son and 13 months after their son’s death, they only had reports sent to their mail and they were told that the hospital don’t keep anesthesia records and nursing notes,so they seek help to some experts to get the complete set of medical records and still they didn’t get any answers and closure at all. Carolyn Clancy,MD said that the biggest barrier for safe care is fear and

Coumadin (non specific name: warfarin) is an anticoagulant, or blood diminishing drug, that is endorsed to numerous patients who are at danger for creating blood clusters that could bring about heart assaults or strokes. Warfarin is near the most astounding purpose recently and simultaneous investigations of medications that provoke ER visits and occurring an expansion in healing center based offices with the affirmation of patients. Anticoagulation treatment stances perils to patients and over and over prompts unfavorable solution events in light of complex dosing, fundamental ensuing watching, and clashing patient consistence. As a result, various patients who meet current evidence based principles for warfarin treatment are not being managed

Breeding, et al. (2013) states that there are a number of published documents addressing the quality, safety, and explicitly medication safety within ICUs worldwide. A large proportion of these studies focused on specific interventions such as: (1) creating “No interruption zones”; (2) addressing drug incompatibilities; (3) implementing automatic drug dispensing systems or electronic prescription of medications; or (4) implementing an ICU pharmacist role (Breeding, et al., 2013, p. 59). It is essential for multidisciplinary teams to be formed for medication safety promotion within this population. These teams would include physicians, pharmacists, and nurses (to also include advanced practicing nurses [APRN], such as nurse practitioners [NPs] or clinical nurse specialists

One of the standards that has been implemented is Standard 4: Medication Safety. The Australian Commission implemented this standard with the intention of ensuring that competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and monitor the effect. (Australian Commission on Safety and Quality in Health Care, 2012) In healthcare, one of the most common treatments is medication. As a result of this, there are many incidences of error, many more than any other healthcare interventions. According to the Patient Safety Network (PS Network, 2015) medication errors account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Medication errors are often a result of the unsafe and poor quality practice of healthcare professionals or system errors. Medication errors are costly and many are avoidable. For this standard

For many patients the scariest part of being in the hospital is having to rely on other people to control your life changing decisions. One large part of this is the medications one is given while in our care. I can only imagine what it must be like for patients to have a stranger to come in and start administering drugs to me. This would be especially scary if I did not know what these medications did, or what negative effects could be caused by taking them. Unfortunately, the fear of medication errors that many patients have are not unfounded. Estimates range from 1.5 to 66 million patients a year have medication errors occur while they are in the care of health care professionals. Considering all of the technology we have at our

It is the nurse’s and pharmacist’s job to be cautious and aware of every medication they are administering by using their critical thinking skills and applying what they know to every situation. Although it is important for these individuals to be able to advocate for their patients, it also imperative that prescribers be aware of the impact they have on their patients as their actions have a domino effect. In conclusion, it is not the responsibility of a single profession to maintain safety in medication administration. It is the responsibility of everyone involved in the patient’s care. Each person who takes steps to improve the process and promote the patient as the number one priority is doing their part in refining how the healthcare system views medication

Risk factors for harmful medication errors reported include the usage of institute of safe medication practices (ISMP) high alert medications, inaccuracy of delivery devices and during the prescription phase of the medication administration process. According to the Harvard Medical Practice study 30% (thirty percent) of patients with medication related injuries died or were disabled for more than six months. (Carlson, 2001, p.18.)

For the purposes of this integrative review, an acute care setting is defined as an adult general medicine medical surgical unit. The expected outcome of the integrative review will be to discover a strategy, intervention, or protocol that can be implemented within the project leader’s healthcare organization to support a sustained change. Upon dissemination and implementation of the findings, a systematic evaluation can be conducted to determine the positive or negative outcomes of the intervention. Each year in the U.S., serious preventable medication errors occur in 3.8 million inpatient admissions and 3.3 million outpatient visits. The Institute of Medicine, in its report To Err Is Human, estimated 7,000 deaths in the U.S. each year are due to preventable medication errors. Inpatient preventable medication errors cost approximately $16.4 billion annually. Outpatient preventable medication errors cost approximately $4.2 billion annually. Dosing errors make up 37 percent of all preventable medication errors. Drug allergies or harmful drug interactions account for 11 percent of preventable medication errors. Preventable medication reconciliation errors occur in all phases of care: 22 percent during admissions, 66 percent during transitions in care and 12 percent during discharge. Approximately 100 undetected dispensing errors can occur each day as a result of the significant volume of medications

Just as any medication is beneficial it can also be very harmful to the body if it were to reach a toxic level. If heparin is being taken regularly the side effects can be harmless but the patient must be aware of what to do if they develop any signs or symptoms. These include easy bruising or bleeding of the gingival mucosa, black tarry stools or frequent nose bleeds that do not stop. Anyone who has these side effects need to notify their physician immediately so the dose can be adjusted. Bleeding is the nursing priority in this instance and it requires immediate intervention. In an infant, they give 75 units/kg IVP over 10 minutes (Kuschel, 2005). This dose is based on weight therefore an accurate weight is very important to have to be sure the infant doesn’t receive a lethal dose of heparin. When giving heparin the nurse or person administering the medication should look closely at the concentration of the medication and be sure they are giving the correct dose of the medication. In the case of the Quade twins the vials did look the same and no one would’ve thought the vials were switched or placed in the incorrect spot. From this incident a change was made, not only for the improvement of healthcare but also for the prevention of a medication error from happening again. We learned from this mistake and implemented changes that improved nursing in ways that we wouldn’t have thought of. From this error, Mr. Quade voiced his opinion and able to get the

Medication administration is a multi-step process that is handled by multiple healthcare professionals. It begins with the prescription that is transcribed mostly by the physician, then dispensed by the pharmacist, and ends with the administration of the medication by the nurse. Throughout this multi-step process, medication errors can occur at any stage of the medication administration process. As expressed by L. Cloete in “Reducing medication errors in nursing practice,” “One third of the errors that harm patients occur during the nurse administration phase: administering medication to patients is therefore a high-risk activity.” Because the nurse is responsible for administering medication to the patient, he/she is considered and viewed as the most accountable in regards to the patient’s safety. Medication errors are one of the most common medical errors that can result in an adverse event that may pose a serious threat to the patient’s safety and well-being. In the article, “An inside look into the factors contributing to medication errors in the clinical nursing practice,” Savvato and Efstratios defined and characterized medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication;

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error