In this essay, the area of clinical skill to be addresses is medicine management. The chosen clinical skill that is being explored for discussion, evaluation and critical analysis is medication administration with focus on causes of medication Error.
According to NMC essential skills definition, Medicines management is “the clinical cost effective and safe use of medicines to ensure patient gest maximum benefits from the medicine they need while at the same time minimizing potential harm “(NMC 2010, P4)
Alexander et al (2004) describes it as a system of process and behaviour that determines how medicines are used by patients. It elaborates that with this system, “patients are put at the centre of care” they are better informed and their care is targeted at the point of delivery by maximizing the use of resources and making excellent use of professional skills and knowledge.
These principles of medicine management also addresses in appropriate and in effective use of medicines at all times.
In other word, medicine management is a comprehensive intervention which encompasses the knowledge of nurses and activities that are performed to assist patients in achieving the greatest benefit and outcome (Neagle 1999)
For this essay, the area of focus for evaluation discussion and analysis on professional issues that underpins or influence how medication administration is undertaken within the context of patient care shall be demonstrated with the medication administration skill.
This is the preparing, giving and evaluating the effectiveness of prescription and non-prescription drugs. Medical centres across the world strive to provide safe medicine administration (Papa and Richards 2010).To reduce risks, medication must be taken correctly and one must understand the right way to administer them.It is therefore important to use medicine as directed.
One can never be too careful when it comes to medicine administration, especially as up to 10% of patients experience unwanted side effects or reactions and from research administration errors make up to 60% of all drug error.
The guiding principles
Nurses are responsible for administering medication within their scope of practice.
Nurses should be about the effects, side effects and intervention of medication.
Nurses are at the front line of medicine interventions and care, therefore they need to understand not only the issues related to the administration of medicine, incorporating the 10 Rights (R’s) but also be knowledgeable, skilful and be aware of the full medication journey such as Movement of drug within the body (absorption, distribution, metabolism and excretion), and the effects of drug and it’s mechanism of action in the body.
The rights of medications administration are there to reduce harm caused by medicine errors, also to protect the interests of the patient and the nurse administrating. Following these guidelines for medicine administration implies medication error will not occur (Macdonald 2010).
10 Rights of medicine administration
Right Patient: Ensure medications are administered to the patient by asking the patient to identify themselves.
Right medication: The prescription of a drug should be clear and legible. The generic name not the trade name should be used. One must check name of the medication, the expiry date, the prescription making sure medications, especially antibiotics are reviewed regularly.
Right dose: Check the prescription, confirms correctness of the dose using the BNF or local guidelines, if necessary, calculate the dose and have another nurse to calculate the dose as well.
Right route: Check the prescribed route and confirm that the patient can take or receive the medication by the ordered route.
Right time: Ensure you check the frequency of the prescribed medication, one should double check you are giving the prescribed at the correct time and confirm when the last dose was given. Ensure regular PRN medications are reviewed and prescribed as regularly if necessary. A drug needs to be administered at the right time(s) for effectiveness outcomes.
Right patient education: Ensure the patient understands what the medicine is for, let them know they can contact a healthcare professional if they experience side-effects and reactions
Right documentation: Ensure you have signed the medication after it has been administered, ensure medication is prescribed correctly with a start and end date if appropriate. One should document when the patient has taken their administered and why?
Right to refuse: Ensure you seek the patient consent to administer medications, patients do have the right to refuse medication if they have capacity to do so.
Right assessment: Ensure you check that the patient actually needs the medication, check for contraindications and baseline observations if required.
Right Evaluation: Ensure the medication is working the way it should, reviewed regularly and on-going observations if required.
Nurses should follow the 10 rights of medication administration. The first Five Rights of medication administration is from the NMC and Nice guidelines while the last five are ungratified checks that has been suggested by multiple US nursing boards and research panels to enhance patient safety.
In view of all guidelines principles and strict adherence to professional policy and guidelines, various researches had shown that medication error is prevalent in healthcare.
According NMC professional conduct which stated that to minimise potential risks associated with medication management, nurses should work within the scope of practice while being aware of their own level of their accountability and social responsibility”
However, various researches had shown medicine administration is prone to errors, which depending on the error can cause patient injury, increased hospital stay and significant legal expenses (Pape 2001)
In 2007, 72,482 medication incidents were reported to the national patient safety agency (NPSA)(2009a), although the majority of errors caused no harm, this is unacceptably high figure. This recognised that the task of medicine administration is becoming more complex as a result of large number of medicines on the market and the various administration route available (Tang et al 2007)
Elliott and Liu (2010) argue that the quantity of drug administration or occurrence of a medication error is not solely a matter of adhering to the 5R’s. Jones (2009) states that the use of checklist, such as the 5R’s does not fully address the issues related to the cause of medication errors. Choo et al (2010) argues that these rights fail to reflect human, system and environmental factors which are the key causes of drug errors.
Tang et al (2007) divided medication management into four stages: prescription, transcription, dispensing and administration. The NPSA (2009a) noted that there are more opportunities for errors during medication administration than at any other stages of the process. The NPSA (2007) reported that 1 in 10 patients experience medication related errors.
Medication error as define by NPSA (2007) is an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicine advice, regardless of whether harm has occurred or was possible. NPSA (2007).
Factors that contribute to medication errors
A study carried out by (Tanget al 2007) on nurse’s views of the factors that contribute to medication errors. In his study, Participants were asked to complete a semi-structured questionnaire consisting of three parts: a narrative description of the error, the nurses background and the contributing factors. Nurses were given eight categories and 34 conditions to choose from to identify the contributing factors to these errors. The result shows that the three most common categories selected were personal neglect, a heavy work load and new staff. Others included unfamiliarity with the patient’s medical history and medication, complicated prescriptions and orders, insufficient training.
The research show that the three most common conditions associated with medication errors were needed to solve other problems while administering drugs, advanced drug preparation with rechecking and newly qualified staff. According to the research, 72 nurses who responded, 55 believed that more than one factor contributed to medication errors, as reiterated by Thomas and Panchagnuk (2008). Limitation of the research is the small sample size.
In another study, an interview was conducted by Ndosi and Newell(2008) where 42 nurses were interview and it was found that only 26% (n=11) had adequate knowledge of the pharmacology of the drug they commonly administer. Ndosi and Newell (2008) reported that nurses scored poorly on knowledge of the mechanism of action and drug interactions.
According to (Pape2003, Scott et al 2010) distractions also contributed to medication errors. Staff shortage can also contribute to an error, this is a system failure. (Tang et al 2007).
The NPSA (2007) report that 71% of fatal and serious harm from medication incidents are due to the following:
Wrong dose being written
Wrong frequency being prescribed
Drugs being omitted
Medication being delayed
Wrong quantity being prescribed
Poor labelling and storage
Drug being intended for another patient.
Adverse drug reaction
Allergy to medication
Reason for Human error
It is important to recognise human tendency to make mistakes (Reason 2000, Robson 2013). Errors can happen to anyone regardless of skill, knowledge or expertise (Armitage 2009). Therefore, some errors can be anticipated even in the best organisations (Reason 2000).
Human behavioural models suggests that if there’s more than one way to do something, then people will try every way. People have natural trendies to look for shortcuts. If a drug can be administered via the wrong route, then over time this will happen unless there are barriers to prevent it (Norris 2009).
The NSPA (2008) developed a forethought programme of error prevention to help healthcare professionals identify situation when they are more likely to make an error, for example when they are hungry, tired or stressed. Staff are encouraged to think of the working environment and identify hazards such as time constraints and the degree of risk involved in the task (NPSA2008)
Effects of medication errors on staff
Medication errors left the nurses involved with painful persistent memories and they often blamed themselves (Tang et al 2007). Also, nurses feel incompetent and guilty when they are involved in medication error (Fry and Dacey 2007).
Moran (2008) reported that she felt like she had been treated like a criminal when she was suspended and charged with gross misconduct after making three medication errors.
Consequences for nurses who report medication error.
According to the agency for healthcare research and quality (2014), the consequences for nurses who report medication errors include: suspension from work, disciplinary action, or being reported to the NMC for misconduct can be an issue.
Incident reporting is essential since it had a vital role in patient protection (Francis 2013) Most of the medication errors go unreported (Nursing and Midwifery council (NMC),2007), the most serious medication incidents reported are caused by error in administration (41%) and to a less extent, prescribing (32%). Fortunately, the majority of medication incidents reported have clinical outcomes of no or low harm.
How to reduce medication error.
Information regarding the prevention and reduction of error is widely available (Bates,2007). Armitage (2008) in his word said that there is need to immediately report all near-misses and medication errors, regardless of whether a patient has been harmed, to ensure a learning experience.
The blame culture should be eradicated (Mc Bride-Henry and Fou, Cohen and Shastay 2008, National Advisory Group on the safety of |patients in England 2013, since this can lead to a fear of authority and fear of incident reporting, which in turn can lead to secretive culture surrounding errors (Dickens 2008). Blame should be appointed if there is evidence that the individual was negligent (Armitage 2009).
Francis (2013) advocated transparency, honesty and candour throughout the NHS. Strategies should look at supporting and counselling staff involved in errors ( Schelbred and Nord 2007)
Literature suggests that many medication errors are related to human error and environmental factors, since drug administration often takes place in noisy environments with poor lighting (Jones,2009).
Fry and Dacey (2007) suggested that to reduce human error and environmental factor, such as distractions, protected time during medication administration could be introduced. This includes the use of a bright Tabard (Hitchen,2008) or the use of a visual reminder such as ” do not disturb ” message (Pape et al,2005) whereby patients and staff are discouraged from disturbing a nurse who is administrating medications. Using the visual reminders, the quality of team communication has been linked to improvements in patient outcomes (Institute of health2011).
According to research, the use of tabard or reminders, is more likely to occur because of an improvement in team communication, as all team members are aware a drug round is being performed, thus reducing distractions which in turn reduce medication errors. However, concerns about the use of tabards, including the cost of the tabards, laundering them and potential infection control breaches, were identified by Scott et al (2010)
In another research, attempt to reduce medication errors leads to the introduction of Automated dispensing devices (Bates,2000). Fowler et al (2009) suggest that technology can improve patient safety. In a research done in acute medical unit in Ninewll hosptial in Dundee, ADC seems like a good solution, the incidence of missed drugs was reduced from 30% to 2%, since medications are available when needed. It was also noted that medication expenditure had reduced, since costly top up visits from pharmacy were not needed as there was less waste from expired medication because overstocking had been discounted (Ford and Platt 2010).
Stachowiak (2013) in his research noticed that the use of ADC leads to many nurses queuing at the cabinets to get medication for their patients. The right procedure of using the ADC is to get one patient’s medication, administer it and then go back to the ADC to get the next patient’s medication. Nurses find this time –consuming and, as a result, they were getting all the medication for all patients and storing then elsewhere to save time.
It was noticed that staff were also getting all medication required by midday ready by 9am not considering the fact that patients prescription is likely to change during morning ward rounds, meaning patients may inadvertently get medications that have been subsequently been discontinued. The recommended use of ADC’s is not being followed, patient harm could occur as a result of a process that does not work in practice. ( Stachowiak 2013) .
Nurses will always do the final safety check before patient takes their medication
This shows that technology does not replace judgement or safety protocols (Cohen and Shastay 2008)