Nurses Role in Identifying, Interrupting & Preventing Medical Errors, Essay Example
In the United States of America, the report of the Institute of Medicine (2000) ‘To Err is Human’ has heightened public concerns about medical errors. Medical errors during the course of patient care estimated to have approximately 238,337 potentially preventable deaths among patients (Feng, Bobay and Weiss 310). The most common cause of adverse patient events in health care is medication errors (Leape et al 130), and the total cost to the US Medicare program as a result of patient injury from errors has been estimated as roughly 8.8 billion dollars . Medications are the most common treatment used in health care, and are more rigorously tested than any other health care intervention. Because they are so commonly used, medicines are associated with more adverse events than any other aspect of health care. The most common cause of medication error in an acute setting is a slip error (doing the wrong thing) or a lapse error (not doing something).Nurses play an important role in ensuring patient safety and preventing adverse outcomes. As frontline providers of care, nurses are in a key position to intercept medical error before it reaches the patient. This essay will discuss the important contribution nurses can make in identifying, preventing, and correcting medical errors.
Nurses role in identifying medical errors
Nurses have played a crucial role in identifying medical errors, which vary from acts of the commission to acts of commission. Medical errors occur anywhere within the hospital setup; in the emergency department, ICU, in the ambulance, in outpatient clinics, in pharmacies or even at home. Assumptions put forward that medical errors only involve administering of wrong medications or wrongful performance of surgery. However, nurses’ have played a crucial role in identifying medical errors as:
- Diagnostic errors, which result from a wrong diagnosis or misinterpretation of results,
- Failure of equipment for lack of maintenance, causing injury to the patient
- Infections such as postsurgical infections or nosocomial diseases
- Wrong blood given to a patient or any incidence of wrongful blood transfusion
- Transcription errors causing a patient to receive an incorrect medication
The advantageous part of it all is that nurses located in all parts of the hospital unit. They easily identify the errors, perform the needed action, report the error, and take a role of preventing future errors from taking place((Leape et al 112).
Nurses have identified sentinel events, which form some of the serious medical errors likely to cause death. Sentinel events also likely to cause significant permanent, loss of a body functioning. Such events include suicide, infant abduction, hemolytic transfusion, and surgery to the wrong patient, or the wrong body part.
Nurses role in preventing medical errors
In order to prevent further errors, the cause of the error identified. Error identified upon carrying out a Root Cause Analysis (RCA) process, especially when a serious incidence occurs (Institute of Medicine 45). This aims at identifying causative factors of mistake. Nurses have contributed in discussing the safety issues where leaders support and implement necessary changes. In this case, nurses have a crucial role in giving out information about the medical error, when it happened, and how it happened. Earlier RCA results studied to help pinpoint the issue. Nurses then brainstormed of such incidences, what they should do in future occurrences.
In the case of suicide or abduction, for example, there could be a problem with the staffing and monitoring. There could be few nurses, with overwhelming duties to perform. When the ratio of nurses to the patient is higher, there is a high possibility of performing medical errors. A nurse in that case supposed to handle a multiple of events (Battles et al 115). This results into distraction of the nurse leading to loss of focus on the various tasks. The patient intending to abduct takes advantage of the situation and escapes. Suicide mostly witnessed in the psychiatric patients. If there is a problem with staffing, then a patient unknowingly or intentionally commits suicide. Patients reported to hang themselves in closets or bathrooms. Others especially those suffering from stress and depression, and not given significant attention by the nurses, counselors, may end up while others jump from hospital roofs. To prevent future cases of the same, the nurses have developed a schedule where they work in shifts to avoid fatigue and exhaustion. They have made a timetable enable them to have night-offs and day-offs. They also suggest for the number of nurses to be increased. They also suggest for more security guards in the hospital environment.
In a case where blood transfusion error occurred, for example, nurses do the follow-up. They check if the specimen mislabeled, or maybe the handwriting on the label was difficult to read. Some other error could be the improper patient identification of the label. Nurses from this point take the next step to avoid future mistakes of the same kind. They may opt to develop a computerized labeling technique to avoid “difficulties in reading”. The staff directly involved in committing such errors evaluated and given time to speak out their views.
Nurses role in correcting medical errors
The nurses have developed a way to deal with a medical error immediately by reviewing all possible causes of the error done. The physicians alerted while, at the same time, an incident report taken. Nurses involved in tracking and identifying any system problem. Discovery of the happening and ways to prevent a similar occurrence in future does at this point.
Nurses and pharmacists have reported wrongful prescription. An example is mistaking “u” for “0” when “u” written to represent units. It could also be mistaken for or “4”. This causes an overdose for a patient. The nurses have it that there is no abbreviation for the unit, and one has to write it out in full. The issue of a leading zero e.g. 0.5mg and a trailing zero 5.0mg bring confusion (Leape et al 78). The nurses with the help of ISMP discourage the use of the trailing zero when using decimal points, and this has significantly corrected such medical errors.
Nurses have the responsibility of administering medication (Institute of Medicine 15). They have had to know all about a given drug, i.e. the administration routes, the side effects, and the contraindications. Before attending to a patient, a nurse needs to measure the body temperature, the weight and identify the allergies the patient would be suffering. The knowledge of these enables correction of any medical error that could arise. Nurses have taken the responsibility of ensuring that all medical facilities take time to introduce and orient new nurses of the policies, procedures, and guidelines of administering medication. They have developed standard medication schedules that require a second person to verify a dose if need be. The nurses also have aired the necessity of training all medical staff on the operation and use of medical equipments in case of emergencies. All this steps play a significant role in correcting possible medical errors.
As discussed, nurses have a substantial role in identifying, preventing, and correcting medical errors. They serve a significant role in the hospital setup. Nurses have identified a wide range of reasons as to why medical errors occur: whereas human errors accounts for the errors, it only contributes to a small portion. Most human errors directly relate to fatigue and exhaustion.
Their role of reporting medical errors is as weighty as one’s life. If surprisingly, nurses did not report errors, then more patients stand a chance of adverse preventable consequences. Nurses have even imposed a rule of carrying out the RCA process for all adverse medical errors to prevent future occurrences of similar cases (Battles et al 25). In earlier days staff feared to report medical errors since it followed with blames for those involved. Since the hospitals have moved into “blame free” system of organization, all medical staff has no reason not to report a medical error.
Battles, J. B., Kaplan, H. S., Van der Schaaf, T.W., &Shea, C. E.. The attributes of medical event reporting systems for transfusion medicineArchives of Pathology & Laboratory Medicine. 122 (1998), 231−238.
Dunton, N., Gajewski, B., Klaus, S., Pierson, B., “The Relationship of Nursing Workforce Characteristics to Patient Outcomes”OJIN: The Online Journal of Issues in Nursing. Vol. 12 (3) (2007). Manuscript 3.
Institute of Medicine. To Err is Human: Building a Safer Health System.Washington DC: Author, 2000.
Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., et al. System analysis of adverse drug events. JAMA, 274, (2000). 35−43.
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