A critical care nurse tries to catch up with her morning medications after her patient’s condition changes and he requires several procedures. He is intubated, so she decides to crush the pills and instill them into his nasogastric (NG) tube. In her haste to give the already-late medications, she fails to notice the “Do not crush” warning on the electronic medication administration record. She crushes an extended-release calcium channel blocker and administers it through the NG tube. An hour later, the patient’s heart rate slows to asystole, and he dies…
A patient returns from surgery, anxious and in pain, with several I.V. lines and an intracranial pressure (ICP) monitor in place. The I.V. tubing used in the operating room differs from the tubing used in the intensive care unit (ICU). In her haste, the ICU nurse prepares to inject morphine into the patient’s ICP drain, which she has mistaken for the central line. She stops just in time when she realizes she’s about to make a serious mistake…
There are four steps in the medication process where errors can occur:
Prescribing. Physicians may inadvertently prescribe a drug that is inappropriate for a patient because of known allergies, potential drug interactions, or existing medical conditions like high blood pressure. When they are working from memory, they may jot down the wrong dose or frequency—or even get the name of the drug wrong, since so many sound alike. Many studies have found that the majority of all medication errors (up to 50 percent) occur at the prescribing stage.
Transcribing. Transcription errors occur at the pharmacy and generally involve illegible handwriting on a paper prescription. Even when a prescription is written legibly, a busy pharmacist may enter it into the system incorrectly. Transcription faults are the smallest category of medication errors.
Dispensing. When pharmacy staff is busy or distracted, they may grab the wrong medication or dosage off the shelf or count pills incorrectly. It may also be considered a dispensing fault if the pharmacist fails to catch a known drug allergy or potential drug interaction.
Administering. Errors at the bedside make up the second largest category of medication errors—between a quarter and a third, depending on the study being cited. These occur anytime a patient gets the wrong drug or wrong dose, misses a dose, or is medicated at the wrong time.
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.
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