Medication Errors-Why?

NeosynephRN · Apr 7, 2008

ummm becuase we are humans and humans make mistakes.

I know that is not helpfull, but is the reason I think of. I mean of course we are pulled in a million directions at once, and have alot going on..that is no excuse. I mean everyone will make a mistake, the key is in owning that mistake and learninfg from it.

buzkil · Apr 7, 2008

Show me a job/profession(or any area of life) where mistakes are not made. I don't think you could find one. It's the human thing, like calla said. Even if we all only had one uncomplicated patient a piece there would still be mistakes. Stuff happens. I made a med error once involving giving a patient another patients meds(several meds). It was not a busy day. I only had 4 patients. All the patients had identity bands on. I don't know, it just happened. I made a mistake.

hikernurse · Apr 7, 2008

Same reason as the others listed. Nobody wants to make a med error. When one is made, most nurses really agonize over it, even when no harm results.

Of course, sometimes med orders don't get sent to Pharm when they are on the chart. Sometimes a new order slips in. Sometimes the wrong med is sent up. Ultimately, the nurse is responsible for checking, though.

justme1972 · Apr 7, 2008

I'm a student, but I have recently discovered a really good reason for med errors.

I read somewhere, where 25 to 30% patients that stay in the hospital have some type of med error happen in the course of their stay. Whether it was the wrong drug, wrong dosage, etc.

If this is such a HUGE problem in hospitals, then why in the heck do nursing schools treat pharmacology as if the class doesn't matter?

At my school it's a one semester hour course, ZERO lecture, ZERO review, ZERO explanations, ZERO question and answer sessions...you read the book and show up for the exam.

And I am not taking a distance learning course...they just don't teach it in a regular classroom.

Why oh why, they insist on this, I have no idea.

ArwenEvenstar · Apr 7, 2008

I'm a student, but I have recently discovered a really good reason for med errors.
I read somewhere, where 25 to 30% patients that stay in the hospital have some type of med error happen in the course of their stay. Whether it was the wrong drug, wrong dosage, etc.
If this is such a HUGE problem in hospitals, then why in the heck do nursing schools treat pharmacology as if the class doesn't matter?
At my school it's a one semester hour course, ZERO lecture, ZERO review, ZERO explanations, ZERO question and answer sessions...you read the book and show up for the exam.
And I am not taking a distance learning course...they just don't teach it in a regular classroom.
Why oh why, they insist on this, I have no idea.

I'm not so sure that more emphasis on pharmacology would help. I've been a nurse 17 years, and none of my med errors were related to lack of knowledge about pharmacology.

When I think back to med errors that I've made, here are some of the common reasons:

* Simple oversight. Ie: The patient was due for 8 different meds at 9pm. With so many due at once, I overlooked one.

* The med dose or time was mis-printed on the MAR by pharmacy. (yes, I know, I should have double checked the original MD order in the chart before giving it.)

*The chaotic, hectic atmosphere of some nursing units. When you are pulled in 12 directions at once...mistakes happen. Ie: You were suppose to give half a pill, but in the chaos you were distracted and forgot to cut it in half before administering.

Wendy_RN · Apr 7, 2008

I believe staffing ratios play a huge role in med errors. It is impossible to check meds against the original order and still administer them on time. If they are not administered within a certain window of time, then of course that is a med error. Nurses are pulled in so many different directions at once that unfortunately a med error will occur at some point. Yes, we are human too and we are going to make mistakes.

santhony44, MSN, RN, NP · Apr 7, 2008

I agree. I think that some factors can be changed, but the human factor will still always be there.

fultzymom · Apr 7, 2008

i think there are several reasons for med errors. first, we are human and none are perfect. if there is a nurse who tells you they have never made one, then they have either always had a desk job or they are lying to you. i think a lot get made when people get in a hurry and are not paying enough attention. sometimes they are made because someone is tired/did not sleep enough before coming into work. some people do not do their checks to make sure they are checking the meds like you are supposed to. there are also many distractions around you. i do not like people bothering me when i am passing meds. if there is an emergency, stop me. if it can wait, please wait.

if i think of anything else, i will add.

leslie

ktwlpn, LPN · Apr 7, 2008

I'm in LTC and our med passess are for 22 to 30 residents. We have our share of mistakes due to a break down somewhere in the system but where I work I also see alot of mistakes due to the environment.It's tough to pass meds with a confused sceamer attached to your med cart and with our "restraint free" policy if we don't have sitters available then we have to monitor the resident's safety.

Frequent distractions (if we don't have a unit secretary then we answer the phone) also family and other residents' needs must be met. Also in my experience unless you are the resident and you are waiting for your "perckies" then you really don't care about any one else's medications. Temperature extremes ( it seems to always be SO HOT in there-try passing meds when sweat is trickling into your eyes) We are still on the 24 hour clock and each shift uses a different color ink-evenings is still green,nocs is red,day is black.The older I get the more difficult it is to discern the difference between the green and black. Besides the fact that my eye sight is not what it used to be (why are those labels getting smaller and smaller?) I think I am also getting shorter-or at least my arms are.I can't read the MAR and see the labels in the lowest med drawers at the same time.I look like a jack in the box-no wonder I am wiped out after the am med pass.

Botton line-nurses are human and mistakes are always going to be made..

espritjolieRN · Apr 7, 2008

IMO they occur primarily because the staff is overworked and overloaded with way too many responsibilities. Think about it, when you're moving as fast as you can to try to keep up with everything you have to do AND you're always automatically thinking 3 steps ahead so you can be as efficient as possible you're going to get distracted and med errors are gonna happen.

So you can decide that med errors will resolve with more education and then tell a class of students, you need to be in the moment and slow down and realize that the patient's life is in your hands... But the simple fact is RNs are overloaded and med errors will ONLY lessen when THAT is addressed.

merellis2009 · Apr 7, 2008

In addition to what everyone else said.....

fragmentation of healthcare