Drug errors can include miscalculation, over- dosing and under-dosing Preston, 2004). However, drug-related incidents are rarely a result of isolated thoughtlessness. The underpinning causes are often complex and multifaceted, and nurses tend to view them as multiple-cause incidents (Preston, 2004). Drug administration forms a major part of the clinical nurse’s role. Medicines are prescribed by the doctor and dispensed by the pharmacist but responsibility for correct administration rests with the registered nurse (Sashes 1999).
Each registered nurse is accountable for his/ her practice. The patient is expected to receive the correct medication at ACH drug round but several studies have shown that this is not always the case (Fernery 2006). Medication errors do occur and are a persistent problem associated with nursing practice (Sashes 1999). This problem was identified recently on Ward 24 a few drug errors had occurred, one error resulted in a service user requiring medical intervention.
The Nursing Midwifery Council (2007) guidelines which all qualified nurses must adhere to state that in exercising your professional accountability in the best interest of your service user the registered nurse must know the therapeutic dosage, side effects, recreation, and contra-indications, be certain of the identity of the patient to whom the medicine is to be administered , check that the prescription, or the label on the medicine dispensed by the pharmacist is clearly written, has considered the dosage, method of administration, route and timing of the administration in the context of the condition of the service user and co existing therapies, checked the expiry date of the medicine to be administered , check allergy status, contact the prescribe or other authorized prescribe without delay where contraindications to the prescribed dedications are discovered, or where assessment of the service user indicates that the medicine is no longer suitable, make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring that any written entries and the signature are clear and legible. All the above should be adhered to when co-ordination a drug round. When the drug errors were identified the service user was checked immediately for side effects, the doctor was informed of the error and l, the ward manager or the on-call manager was informed Of the error. An incident form was completed which also alerts the pharmacist and clinical lead managers.
The service users relatives were informed of the incident and a clear concise report was also documented in the service user’s electronic reporting notes. TASK 2 The first step in deciding how to address a problem in practice is to identify exactly what the problem is which will involve defining what problem or problems exist in a given situation (Aligarh’s 2012. ) This includes exploring what people perceive to be problematic in a situation, and what this means in terms of any required intervention or change in practice. One way to approach identifying the cause of a problem is to carry out a detailed problem analysis (Van Behooves et al 2003, European Commission 2004).
This ensures that every aspect and possible cause of a problem is considered, and that causes and effects are distinguished. It may be difficult to put aside assumptions and personal opinions about a particular situation (Paton and McAllen 2008). Using a tool or framework to conduct a systematic problem analysis can help challenge these assumptions and opinions, and provide prompts to investigate causes that are not immediately obvious. Pare et a (2011 ), suggests changes in practice are more likely to be successful if those required to change their behavior or working practice understand why the change has been made. Problem analysis is effective when those directly involved in the situation are invited to explore the problem and suggest solutions. Hose Change & Kelly (1995) problem solving model to help process the direction for finding a solution. However solutions have to be realistic, achievable and developed in the right order. I discussed the five points of the model with staff define, assess, plan, implement and communicate. By asking y colleagues to contribute to the problem analysis this might highlight differences in what they perceive to be problematic. Those involved in the process felt they had contributed to resolve the identified problem. DEANE THE PROBLEM Several drug errors had occurred on the ward this although not intended could cause unnecessary harm to a service user. Ad to identify why and where the error was occurring. Was the error at the stage of prescribing, dispensing or administration? Could this be due to inexperienced staff not knowing the correct therapeutic dosage of the prescribed drug, staff heritages or interruption’s when commencing the drug round. Medication errors are not uncommon and often go unrecognized and unreported. National patient Safety Agency (2007) research shows that almost one in ten patients experience medication- related harm. However, many mistakes go unreported as staff often do not realist the drug error has occurred. Any nurse who has made a drug error knows how stressful this situation can be.
Registered nurses are accountable for their actions and omissions when administering any medicines and must take responsibility for any errors they make. However, the increasing demands placed on nurses can render them more prone to drug errors. Overwork can affect concentration and competence and this can be exacerbated by erratic working hours and stress, while complacency can also lead to mistakes (Parish, 2003). While nurse fatigue is a commonly cited cause of drug errors, others include illegible physicians’ handwriting and distractions (Mayo and Duncan, 2004). There is a range of opinion about what constitutes a drug error (Sashes, 1 999) and nurses, pharmacists and doctors may not actually agree on what the precise definition is.
The National Patient Safety Agency sees the definition of the US National Coordinating Council for Medication Error Reporting and Prevention: ‘A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer (Smith, 2004). We decided to use a Five Whys approach to analyses the problem. This tool explores the cause of a problem by repeatedly asking why something happens until the cause of the problem is identified. We asked the question why drug errors occur, and kept repeating it until no further answers could be enervated. Each answer to the question enabled us to develop the question further. The last ‘why’ suggested a possible solution. Latino, (2004) suggests one of the difficulties of using the Five Whys analysis is that it does not always illustrate the links between causes.
It also relies on being able to articulate the cause or causes of a problem and directly linking them to solution, which is not always possible. We found the tool useful for guiding us when thinking about the problem. GENERATE ALTERNATIVES researched the current literature on reducing drug errors one of the ethos recommended for effectiveness was for nurses to wear a red tabbed when administering medications displaying the words Drug Round in Progress Please Do Not Disturb. Also spoke with the Pharmacist who recommended regular audits of the drug charts this also provided a fresh eyes approach to the problem. Audits would ensure legible handwriting, inappropriate use of decimal points, abbreviation’s and correct times and dosages.
This would ensure clearly written medicine charts for nurses to read and follow. Discussed all the above with my colleagues and further problems were identified. Staff shortages, interruption’s from telephone calls and relatives were just a few raised. Observed several drug rounds and found many interruptions were occurring. I also found the area staff dispensed medication open to interruptions Together we implemented the use of a fishbone diagram also referred to as a cause and effect diagram. By implementing this we were able to establish causes and plan there outcome. ALTERNATIVE ONE Medication to be dispensed by a nurse from the clinic room and another person to assist with the drug round.
All service users to be brought to clinic room for medicine to be dispensed. This would be less stressful and fewer interruptions would occur for the qualified nurse dispensing and a more private area achieved for the service user. ALTERNATIVE TINT Introduction of red tabbed to be worn when dispensing medication. Research suggests the use of tabors decreases medication errors. EVALUATE AND SELECT THE OPTIMUM SOLUTION All staff was in agreement that both alternatives should be tried alongside with introduction of auditing of the medicine charts. To enable this to be implemented we completed a SOOT analysis diagram. STRENGTHS Nurses remain with service user during administration
Nurses gain consent from service user Nurses have time to explain medication to service user WEAKNESSES Medications missing from trolley not re-stocked Staff shortages and poor staff to patient ratio Staff, service users, telephone and visitor interruption during drug rounds OPPORTUNITIES Protected time for drug rounds Identifiable clothing (implement red tabors) implement WISH to be able to undertake responsibility of assisting qualified nurse with drug round Night staff to re-stock medicine trolley Display signs stating nurses administering drug should not be disturbed THREATS Change in practice can make staff resistance or non-compliant Newly qualified staff not confident in administering medication Staff shortage Funding for tabors Laundry issues IMPLEMENTING THE SOLUTION All staff were in agreement to the following been implemented. All drug rounds to be designated to the clinic room. Sign to be displayed on door stating drug round commenced do not disturb.
Service user to be escorted to clinic room by WISH and qualified staff member dispenses medication. Staff member who dispenses medication to wear red tabbed. Under no circumstances should the person who is administering medication be stubbed or asked to take telephone calls. Data protection was taken into account but no issues were raised. EVALUATING THE OUTCOME Staffs have been administering medication following implementation of the new guidelines for three weeks. No drug errors have been reported in that time. Staff states they prefer the new guidelines they feel less pressured and hurried to complete the drug rounds. More time is been given to service users from staff to explain medications and build relationships.
Staffs feel more confident and competent within their roles with no drug errors occurring. I do a weekly audit of medicine charts and this has picked up a few discrepancies which could have resulted in further drug errors occurring. TASK 3 am currently employed as a Band 6 Assistant Ward Manager on a 19 bedded mixed sexed Specialist Dementia Assessment unit based at Airedale Hospital. Have held this position for approximately four years. One of my main management responsibilities is to ensure a safe effective workplace for all and this is achieved by working in partnership with the Ward Manager. Another of my management responsibilities is to supervise 35 employees ender guidance and direction of the Manager.
At present time work within a multi-disciplinary team which aims to provide a high evidence based standard of care to the Older Adult who has a diagnosis of Dementia or memory impairment. I assist the Ward Manager by ensuring high standards of care are formulated and delivered to all service users whilst taking into account Trust policies and procedures, data protection issues, local government policies and Nursing Midwifery Council competencies are maintained. I offer management supervision to a small group of colleagues and this is done on a wow monthly basis, I also complete their yearly appraisals. This procedure helps identify any work related or personal issues.
It also helps me plan training and encourage individuals to develop themselves further. Advise the Ward Manager on matters relating to the provision of service, and in the Ward Managers absence act up on their behalf this duty is also shared between me and the other Assistant Ward Manager. For my future development needs I will enquire about new courses especially the ones which are management lead has I feel this will allow me to develop rather in my role and provide better management direction to others. I will ensure all my mandatory training is up to date and attend yearly internship updates which allow me to mentor students and offer partnership to newly qualified nurses.
I will continue to receive management and clinical supervision which believe helps me focus my role and provides me with management direction. I keep myself up to date with ever changing clinical practice and attend conferences to cascade new ways of working to the team. REFERENCES Change, R. Y. , and P. K. Kelly, (1995). Step-by-Step Problem Solving, Dutton, New York, NY. Fernery RE, (2006). Clarification of terminology in medication errors: definitions and classification. Drug Safe. V 29:101 1-22. Mayo, A. And Duncan, D. (2004). Nurse perceptions of medication errors: what we need to know for patient safety. Journal of Nursing Care Quality, Latino, R. J (2004) Optimizing FAME and RCA efforts in health care.