Download med-surg 1: medication error paper

Running head: GIVING THE WRONG DOSE
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Giving the Wrong Dose and a Way to Prevent It
Stefanie Shorey
University of South Florida College of Nursing
Abstract
Medication errors occur every day in the hospital. Most of these errors can easily be
preventing by using the five rights when giving medications: the right drug, the right patient, the
right time, the right dose, and the right route. However, even if the five rights are always
followed, such errors such as giving the right dose may occur. The most common reason would
be that orders are written incorrectly or illegibly by doctors, and then misread by nurses. The
following paper describes this error, as well as a new method to correct it.
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Every year, at least one medication error a day will occur to a hospitalized patient
(Radley, 2013, p.1). As nurses, it is part of our duty to prevent these errors. Practicing the five
rights is one of the easiest ways to prevent such medication errors. A common medication error
starts at the beginning of the chain, with prescribing and reading the doctor’s orders. The
Institute of Medicine has recommended using a computerized provider order entry (CPOE) to
help reduce the amount of order errors (Radley, 2013, p.1). With an electronic order, there will
be fewer errors in reading the order, thus, preventing giving a patient the wrong dose or wrong
medication due to an illegible order.
A serious medication error is giving the wrong dose of a medication. The difference
between 8mg or 8µg is a big difference, which when written out, could easily be mistaken due to
a doctor’s handwriting. A simple added or subtracted zero in a dose could mean the difference
between a patient living and dying. It is a serious error that should not be happening, but can so
easily occur. Medication errors, prior to the 2008 implementation of CPOE, were estimated to be
around 17.4 million a year. When using CPOE, medication errors were reduced by 12.5% in just
one year (Radley, 2013, p.4). However, even with the CPOE reducing errors, other types of
errors have actually doubled, such as duplicate orders, since the implementation of CPOE
(Wetterneck, 2011, p.776). However, many times, the duplicate orders would occur during a
shift change, or a miscommunication among the various doctor’s for a single patient
(Wetterneck, 2011, 777). The CPOE system does have warnings that will pop-up if a duplicate
order is made, but this is sometimes ignored or there is no warning because the medication
database doesn’t recognize the same medication if one is oral and the other IV (Wetterneck,
2011, 780).
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However, as a nurse, it is important to check the complete list of medications prior to
giving them to the patient; therefore, an incorrect dose is less recognizable than a duplicate
medication. So, because of this, the CPOE is more important to prevent dose errors, than with the
possibility of duplicate orders. Even with the CPOE, nurses need to be aware of a patient’s
previous prescriptions and those they are receiving in the hospital because human error may still
occur when imputing into a CPOE.
The one medication error I am most concerned about making is bringing the wrong
medication into the patient’s room because of distractions. Almost every clinical day, my
preceptor is interrupted while at the AccuDose, and it would be so easy to pull the wrong
medication for your patient because you can easily grab a medication from the wrong pocket.
Luckily, however, most hospitals have a secondary check prior to giving medications to your
patient, in which you have to scan each medication in prior to giving it to your patient, which
helps prevent incorrect medication administration. As a new nurse, I will also try to avoid getting
distracted while pulling medications. I also plan to only pull one patient’s medication at a time,
therefore I prevent mixing patient’s medications and prevent giving the wrong medication to the
wrong patient.
In conclusion, a serious medication error is giving the wrong dose of a drug to a patient.
Fortunately, there is a growth in technology for health which includes the CPOE system. With
this system, orders are no longer hand written, rather electronically written. This helps not only
with correct dosing, but with incorrect medications being prescribed because not everyone has
legible handwriting. However, with each technological advance, there are always issues. The
CPOE system’s major problem is with duplicate orders. In my opinion, a good nurse would
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easily see a duplicate order, but not always know that a wrong dose was prescribed. So, the
CPOE is more helpful than hurtful.
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References
Radley, D., Wasserman, M., Olsho, L., Shoemaker, S., Spranca, M., & Bradshaw, B. (2013).
Reduction in medication errors in hospitals due to adoption of computerized provider
order entry systems. J Am Med Inform Assoc, 00:1-7. Retrieved September 25, 2014,
from JAMIA.
Wetterneck, T., Walker, J., Blosky, M., Cartmill, R., Hoonakker, P., Johnson, M., et al. (2011).
Factors contributing to an increase in duplicate medication order errors after CPOE
implementation. J Am Med Inform Assoc, 18:774-782. Retrieved September 25, 2014,
from JAMIA.