Analisis De Articulo Farmacologia

Analisis de Articulo

Nurs 1050

Prof. Alice Romero

Medication errors:

Don’t let them happen to you

Mistakes can occur in any setting, at any step of the drug

administration continuum. Here’s how to prevent them.

According to the landmark 2006 report “Preventing Medication Errors” from the Institute of Medicine,

these errors injure 1.5 million Americans each year and cost $3.5 billion in lost productivity, wages, and

additional medical expenses. Medication administration is a complex multistep process that encompasses

prescribing, transcribing, dispensing, and administering drugs and monitoring patient response.

An error can happen at any step. Although many errors arise at the prescribing stage, some are intercepted

by pharmacists, nurses, or other staff. Unfortunately, most administration errors aren’t intercepted.

Recent technological advances have focused on reducing errors during administration. The Institute for Safe Medication Practices (ISMP) has identified 10 key elements with the greatest influence on medication use,

• patient information

• drug information

• adequate communication

• drug packaging, labeling, and

nomenclature

• medication storage, stock, standardization,

and distribution

• drug device acquisition, use, and

monitoring

• environmental factors

• staff education and competency

• patient education

• quality processes and risk management

Patient information

Accurate demographic information (the “right patient”) is the first of the “five rights” of medication administration. Required patient information includes name, age, birth date, weight, allergies, diagnosis,

current lab results, and vital signs. Barcode scanning of the patient’s armband to confirm identity can reduce medication errors related to patient information.

Drug information

Accurate and current drug information must be readily available to all caregivers. This information can

come from protocols, text references, order sets, computerized drug information systems, medication

administration records, and patient profiles.

Adequate communication

Many medication errors stem from miscommunication among physicians, pharmacists, and nurses.

Communication barriers should be eliminated and drug information should always be verified. One way

to promote effective communication among team members is to use the “SBAR” method (situation, background, assessment, and recommendations). Clinicians had failed to communicate to other team members that her initial cardiac arrest had occurred shortly after she’d received the medications improperly.

Drug packaging, labeling, and nomenclature

Healthcare organizations should ensure that all medications are provided in clearly labeled unit-dose packages for institutional use. Packaging for many drugs looks similar. Look-alike or sound-alike medications— products that can be confused because their names look alike or sound alike—also are a source of errors. From 2003 to 2006, 25,530 such errors were reported to the Medication Errors Reporting Program (operated jointly by the U.S. Pharmacopeia and ISMP) and MEDMARX (an adverse drug event database). The JC requires healthcare institutions to identify look-alike and sound-alike drugs each year and have a process in place to help ensure related errors don’t occur.

Medication storage, stock, standardization, and distribution

Many experienced nurses remember when critical care units kept a medication “stash,” which frequently

caused duplication errors. Potentially, many errors could be prevented by decreasing availability of

floor-stock medications, restricting access to high-alert drugs, and distributing new medications from the

pharmacy in a timely manner. The Institute for Healthcare Improvement recommends standardized

order sets and preprinted protocols for 75% of the drugs healthcare facilities use. These orders and protocols help clinicians promptly select correct dosing regimens, routes, and parameters while eliminating ambiguous abbreviations and the risk of misreading a prescriber’s handwriting.

Drug device acquisition, use,and monitoring

Improper acquisition, use, and monitoring of drug delivery devices may lead to medication errors.

Some delivery systems have inherent flaws that increase the error risk. For example, at one time, I.V.

medication tubing continued to flow or infuse when removed from the pump. Thus, patients could re- ceive boluses of medications or I.V. solutions, which sometimes had deleterious outcomes.

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