ERRORS IN INTRAVENOUS MEDICATIONS
Introduction
Medication errors are one of the leading causes of injury to hospital patients, with approximately two out of every 100 patients admitted to the hospital experiencing a preventable adverse drug event (2006). Giving medication to the wrong patient or to the right patient in an incorrect dosage or at the wrong time is also commonplace in hospitals, nursing homes, and other health-care settings ( 1994).
Errors in the workplace are not only confined to health care,with the engineering and aviation industry also recognisingtheir inevitability. Research from these disciplines has attributederror occurrence to working environments, a philosophy thathas now been adopted by healthcare institutions. Within thehealthcare environment, institutions must seek to acquire knowledgeabout error prone situations and identify variables associatedwith them in an attempt to change systems and reduce futureevents. This requires some commitment to specific researchactivities, but should be complemented by a non-punitive reportingsystem to facilitate knowledge acquisition from errors arisingin normal daily practice. The variables primarily responsible for medication administration errors are nurses’knowledge of the medications, their length of experience, theirfailure to follow guidelines, the time of day, the day of theweek, workload and staffing levels (2004).
Most medication administration errors result from errors in management rather than from patient factors such as allergic reactions. Many physicians (and most lawyers) tend to consider that all errors result from negligence. Not only is such a judgment unjustifiably harsh, but this kind of thinking can be a substantial barrier to efforts to reduce errors. Although some errors are egregious and can be legitimately considered negligent, the vast majority are not. Minor slips or momentary lapses are far more common, such as writing the wrong dosage for a drug or forgetting to obtain the results of a laboratory test. These kinds of slips and mistakes occur frequently to everyone in everyday life. And, although they are arguably among the most careful people in our society, doctors, nurses, and pharmacists also make mistakes (1994).
The dramatic increase in the number of new medications, including biotechnology products, makes it difficult to keep current on their proper use, and can overwhelm the best intentions of all health care practitioners, including nurses.
Administration of the wrong drug is the most common error that occurs. Factors that contribute to wrong drug error include similar labeling and packaging of products, medications with very similar names and storage of these similar products together. In addition, poor communication is a common cause of administering the wrong drug.
Complications of Intravenous Therapy
Medication errors can be a source of significant morbidity and mortality in the health care setting. Providing intravenous (IV) therapy is a complex health care technology and patients are at risk of experiencing adverse events such as medication errors ( 2004). Increasingly, human error theory is used to investigate adverse events such as these. Therefore, it is important that medication errors be monitored so that similar incidents can be prevented in the future. Problems associated with devices that lead to medication errors should also be reported to health care authorities.
Many medical-surgical nurses also experience difficulty when calculating drug dosages. One study revealed that 56% of nurses could not calculate medication dosages to a 90% proficiency rate. In addition, nurses made significantly more errors in calculating intravenous drug dosages as compared to oral, intramuscular, or subcutaneous drug dosages ( 2004).
When using any method of intravenous medication administration, the nurse must observe clients closely for symptoms of adverse reactions. After the medication enters the bloodstream, it begins to act immediately, and there is no way to stop its action. Thus the nurse should take special care to avoid errors in dose calculation and preparation.
The nurse should double-check the six rights of safe medication administration and know the desired action and side effects ( 2004). If the medication has an antidote, it must be available during administration. When administering potent medications, the nurse must assess vital signs before, during, and after infusion.
Administering medications by the IV route has advantages. Often the nurse uses the IV route in emergencies when a fast-acting medication must be delivered quickly. The IV route is also best when it is necessary to establish constant therapeutic blood levels. Some medications are highly alkaline and irritating to muscle and subcutaneous tissue. These medications cause less discomfort when given intravenously ( 2004).
As a safety alert, because IV medications are immediately available to the bloodstream once they are administered, the nurse must therefore verify the prescribed rate of administration so that the medication is given over the appropriate amount of time. The patients may experience severe adverse reactions if the IV medications are administered too quickly.
An infiltration occurs when IV fluids enter the surrounding space around the venipuncture site. This is manifested as swelling (from increased tissue fluid) and pallor and coolness (caused by decreased circulation) around the venipuncture site. Fluid may be flowing through the IV line at a decreased rate or may have stopped flowing. Pain may also be present and usually results from edema and increases proportionately as the infiltration continues (2004).
When infiltration occurs, the infusion must be discontinued and, if IV therapy is still necessary, a new cannula is inserted into a vein in another extremity. To reduce discomfort, the nurse should raise the extremity, which would then promote venous drainage. To help decrease the edema, the nurse should wrap the extremity in a warm, moist towel for 20 minutes while keeping it elevated on a pillow. This promotes venous return, increases circulation, and reduces pain and edema (2003).
Phlebitis is an inflammation of the vein which is another complication of intravenous therapy (2004). Selected risk factors for phlebitis include the type of catheter material, chemical irritation of additives and drugs given intravenously, and the anatomical position of the catheter. Signs and symptoms may include pain, edema, erythema, and increased skin temperature over the vein, and, in some instances, redness traveling along the path of the vein. Dehydration may also be a contributing factor because of the increase in blood viscosity ( 2000).
When phlebitis occurs, the IV line must be discontinued and a new line inserted into another vein. Warm, moist heat on the site of phlebitis can offer some relief to the client. Phlebitis can be dangerous because blood clots which are called thrombophlebitis can occur and in some cases may result in an emboli. This may result in permanent damage to veins as well as resulting in extended agency care. Phlebitis may be prevented by the routine removal and rotation of IV sites (2004).
Another complication of intravenous therapy is fluid volume excess (2004). This occurs when the patient has received a too-rapid administration of IV solutions. The assessment findings of this condition include shortness of breath, crackles in the lungs, and tachycardia. To provide an intervention for this, the nurse should slow the rate of infusion, notify the physician, raise the head of the bed, and monitor vital signs.
Bleeding can occur around the venipuncture site during the infusion or through the catheter needle or tubing if these become inadvertently disconnected. This complication is common in patients who have received heparin or who have a bleeding disorder (2004). If bleeding occurs around the venipuncture site and the catheter is within the vein, a pressure dressing may be applied over the site to control the bleeding. Bleeding from a vein is usually a slow, continuous seepage and is not serious. Still it merits special attention from the nurse and other medical staff.
In efforts to improve patient safety, healthcare systems need to give first priority to averting the medication errors with the greatest potential for harm. By targeting efforts to avert such errors, hospitals can achieve the most rapid and significant impact on improving medication safety ( 2005).
The ever-increasing complexity of the nursing environment and the current nursing shortage further increase the possibility of error in many medical routines, including intravenous administration of drugs. Demands often exceed an individual’s capacity to function without error, even for highly experienced clinicians. Unnecessary variability in drug concentrations, dosing units, and dosing limits used in different areas of a hospital further complicates infusion programming and increases the risk of harm ( 2005).
Corporate Role
The United States Agency for Healthcare Research and Quality has allocated significant funding for developing reporting systems, and federal legislation has been recently passed to promote voluntary reporting of adverse events like medication errors. Many strategies, such as incidence reports and executive walkrounds, are available for obtaining information about errors, near misses, and other patient safety hazards ( 2005).
Organizational Role
In the United States, an organization was formed that is for the purpose of preventing the incidence of medical errors. The Massachusetts Coalition for the Prevention of Medical Errors was established in 1998 to develop a campaign in the Commonwealth to improve patient safety and reduce medical errors. The goals of the Coalition are to disseminate knowledge and information about the causes of sentinel events and develop strategies for prevention. The Coalition plans to drive improvement by making this information available to health professionals and health care institutions for use in their own quality improvement programs through a statewide campaign. This initiative seeks to strengthen the public’s trust and confidence in the health care delivery system as well, by increasing awareness of error prevention strategies through public and professional education (2006).
There are also some hospitals that have adopted reconciling medications. It is a formal process for creating the most complete and accurate list possible of all pre-admission medications for each patient and comparing the physician’s admission, transfer, and discharge orders against it. Any resulting changes are documented. The reconciling process has been demonstrated to be a powerful strategy to reduce medical errors. At Luther Midelfort Hospital, a series of interventions introduced during a seven-month period successfully decreased the rate of medication errors by 70% and reduced adverse drug events by over 15% (2006).
Project Team Role
Health care professionals must work together in collaboration in order to reduce medical errors, particularly in the administration of medicines. If they will work together, like collaboration between doctors, nurses and pharmacists, proper communication is present thereby reducing the likelihood of medication errors.
According to a research, nurse managers should understand that errors are more likely to occur if multiple steps are required to prepare a medication before administration or if bolus administration of medication is being used. Consideration should be given to implementing a system of centralized preparation for all IV medications and affixing warning labels to all medications intended for bolus administration ( 2003).
Medication administration is a critical skill of the professional nurse, who must understand and follow various steps in the drug administration process to assure patient safety. The nurse must be proficient in medication dosage calculation to safely administer drugs. Errors related to intravenous administration of a drug often results in the most serious injuries to patients (2003).
Individual Role
To administer medication safely to patients, certain cognitive skills are essential. The nurse accepts full responsibility and accountability for all actions that are taken; this includes the administration of medications, whether it is intravenous, oral, or something else.
When a nurse administers an intravenous medication to a patient, the nurse accepts the responsibility that the medication or the nursing actions in administering it will not harm the patient in any way. The nurse does not assume that the medication that is ordered for the patient is the correct medication or the correct dose.
The nurse could be held accountable for administering an ordered intravenous medication that is knowingly inappropriate for the patient. Because of this, the nurse should be familiar with the therapeutic effect, usual dosage, laboratory interferences, and side effects of all medications that are administered (2004).
Demonstrating accountability and acting responsibly in professional practice means that the nurse acknowledges when errors in professional practice occur. Most of the errors that are made by nurses are medication errors (2004), and this includes intravenous medication administration.
Nurses in critical care settings must be familiar with the variety of ways dosages are described. The nurse should understand how to convert and determine equivalent dosages with orders that contain such units as micrograms/minute, micrograms/kg/minute, milligrams/hour, or milligrams/day. For many intravenous drugs, an infusion pump may be used which requires a pump setting in any of the above units. Alternatively, without an infusion pump, a drip factor must be considered with intravenous solutions (2004).
The nurse is the essential link in the prevention of medication errors. Unfortunately, many medication errors are never identified. When an error occurs, it should be acknowledged immediately and reported to the appropriate hospital personnel. This is necessary since measures to counteract the effects of the error may be necessary.
Scope of the Risk
Patient Care
Errors in administering intravenous medications are most of the time human errors that could be a result of other factors. There are some factors that restrict nurses in providing high quality of care. This could be due to nurses’ knowledge of the medications, their length of experience, their failure to follow guidelines, the time of day, the day of theweek, workload and staffing levels.
Other than that, other factors such as a nurse shortage, nurses being assigned heavy patients, low levels of staff training and elderly patients could be the reason for errors in medication administration. In this kind of environment the risk of medication error will be high and harm to patients is highly increased. In addition, long working hours will increase the fatigue of nurses and decrease their concentration. Distraction of nurses in preparing medication will lead to wrong doses or wrong medication given and this will be harmed for patients.
Human error is not only a property of humans -it is a property of systems that include humans. In the end, the best way to prevent errors in giving medication may be as simple as changing the font of the print used in labels, or as complex as changing the purchasing strategies of the entire hospital. By using a systems approach with its potential for rich solutions, the number of errors can be reduced and their consequences mitigated (1994).
Clinical Staff
To protect the health care professional and the patient, the health care professional, for example the nurse, should document the care given and the details associated with it. Charting the statement “physician notified” may be insufficient if at the time the nurse is being questioned about the lawsuit, he or she does not recall which physician and what specific facts were told to the physician.
When a lawsuit is filed, very often, the nurse’s notes are the first thing reviewed by the attorney. The nurse’s assessments and the reporting of significant changes in the assessments are very important factors in defending a lawsuit (2004). Therefore, the nurse should identify the physician contacted, the information communicated to the physician, and the physician’s response. For nurses in practice, the underlying rationale for quality improvement and risk management programs is the highest possible quality of care.
Other Employees
There is a possibility that those nurses who have low knowledge about medication administration and low clinical skills will show aggressive behavior. They could also deal with other employees aggressively because they are under pressure and stress.
Property
There is no risk to property due to medication error.
Financial Risk
Medication errors could cost hospitals a lot of money. As mentioned, lawsuits could be filed against health care professionals. This could cost money not only on the hospitals but also the health care professionals themselves. Even if lawsuits are not filed, hospitals will still have to pay money to the families and extend the length of patient hospitalization. Yearly total national costs (lost income, lost household production, disability and health care costs) of negligence in hospitals each year which includes medication administration errors, of which healthcare costs represent over one-half is estimated to be between 17 to 29 billion dollars (2004).
Corporate Governance
If errors in medication administration frequently occur in a hospital or any other health care setting, some people will not trust that certain hospital or health organizations and the Health Department in general will have a bad reputation. This will cost a lot of money and there will be possible unemployment for most health care professionals as a result.
Conclusion
Errors will always occur, and it is perhaps as well to reflect, particularly in a litigious society, that although the way in which death comes to each of us may be due to an error, death itself is not an error, but a result of life. However, there are certain strategies in which errors could be minimized and even avoided. Ensuring patient safety is a fundamental element of high quality health care and should be the goal of health care organizations, teams and professionals. Providing safe, quality health care to every individual should be a priority for all governments, health care professionals, organizations and institutions.
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