Medication errors threaten patient safety and are increasing problems in the provision of care in the United States (US). The errors related to medication lead to longer patient stays at the hospital. These longer stays and emergency care provided to patients who have suffered medication errors increase the overall cost of healthcare (Mieiro et al., 2019). According to statistics, over 400,000 patients visit healthcare institutions each year due to medication errors (Single Care, 2021). Eliminating medication administration errors by promoting safety, quality, and practice standards can enhance the quality of care, patient safety, and care coordination (Khan & Tidman, 2022). Individual performance and systematic effectiveness are two primary reasons to achieve a culture of safety in healthcare institutions, according to Quality and Safety Education for Nurses (QSEN) (WTCS, 2023). The assessment assumes that identifying teaching and training methods for nursing can help reduce medication errors. According to research, medication administration errors can be reduced significantly by educating nurses on their impacts (Phillips et al., 2019). The assessment aims to analyze medication administration-related safety issues to propose evidence-based quality practices.
Scenario
I experienced an error related to medication administration recently at Mass General Brigham (MGH). A colleague nurse named Betty overdosed on a complex chronic patient with severe pain from Chronic Kidney Disease (CKD). Morphine was prescribed by the doctors in the hospital in case of moderate to severe pain for the patient. Due to the sudden high pain, the nurse got tensed and provided more doses than prescribed. The patient skin immediately got pale, and he was barely breathing. Since the overdosage was not severe, the patient recovered by continued medical procedures.
Reason for Specific Patient Safety Risk
The overdosage of morphine resulted from different situations in the workspace on the day. A patient had died earlier that day in MGH with the same CKD problem as the current patient. Therefore, Betty was having a very hard time coping with the earlier event. Before the medication error, Betty observed the patient and tried to communicate with him about his pain levels. Subsequently, she remembered that morphine was prescribed to the patient. She did not check the prescription on the paper and provided a dosage of 10mg to the patient, which caused an immediate reaction. The prescribed dosage for the patient was only 2mg, which Betty did not review, and the medication error happened (Nosek et al., 2022). Medication errors are preventable at institutions like MGH where resources are abundant. Therefore, the need to plan for safe conduct is necessary to mitigate the errors related to medication administration.
Data and Evidence
According to Food and Drug Authority (FDA), the institution receives over 100,000 reports of medication errors every year. It has also been stated that the institution encounters medication error-related injuries, which are over 400,000 patients per year. The cost of care increases according to the institution (Single Care, 2021). According to Khan and Tidman (2022), the primary reason for medication-related errors is the lack of training of nurses, negligence, low standards of practice, and ignorance towards risk management practices. The unavailability of health literacy is one primary reason for this capacity which causes medication-related errors (Mieiro et al., 2019). For example, in the present case of Betty, she was already disturbed and forgot to review administrative records for the patient before providing the dosage to the patient.