Discuss a common breach of medication administration. please include References

One of the most typical failures in medication administration is “omission errors” which are defined as a prescribed medication that is not given to the patient as required. Such types of mistakes are considered to potentially endanger the lives of patients and affect their heal being.

 The three categories of omission errors include the following:

 Description of the Breach

 Definition: Omission error is one in which a drug is not administered at the correct time or not administered at all. This can be as a result of carelessness, an error in communication, or a problem with the software.

 Examples:

 A nurse failing to consider and practice routine remembering to give a prescribed dose of a certain medication.

 A medication order not being communicated and passed on from one shift to the other.

 This may probably be due to the failure to document the administration of a medication which may create confusion as to whether the said medication was administered or not.

 Impact on Patient Safety

 Delayed Treatment: Inability to receive a dose that is required in treatment may show least therapeutic benefits, deterioration in patient’s condition or even deterioration of the disease.

 Increased Risk of Complications: If particular drugs are administered irregularly, severe consequences or negative impacts may occur including the progression of drug-resistant infections, the worsening of chronic conditions, and others.

 Patient Outcomes: Omission errors can make a difference directly in patient experiences, lead to a longer hospitalization, and higher readmission rates.

 Contributing Factors

 Human Error: Inadequate time, tiredness or general overcrowding at certain hours of the day can make the health care providers to forget the time they need to administer medication.

 Communication Failures: Lack of communication between the shift or between the healthcare providers may lead to failure in documentation of medications that are prescribed.

 System Failures: Some causes include lack of utilization of EHRs, or problems with the manual documentation of medication administration.

 Prevention Strategies

 Implementing Checklists and Reminders

 Always utilize eMAR that has alarms to guarantee that all the doses have been given.

 Improve the medical documentation and create checklists to ensure that no medication is administered after a shift or a weekends break.

 Enhancing Communication

 Handoff has to become more standardized, so that information about matters such as medication administration is well handed over from one shift or from one provider to another.

 There must be compliance checks of all the medication orders and administration records during the team meetings.

 Training and Education

 Moreover, promote as a continuous process, training of healthcare staff regarding medication administration and the impact of omission error.

 Teach the staff about comprehending how to incorporate technology into care, EHR technology and eMAR systems.

 Utilizing Technology

 Encourage hospitals to establish and adopt barcode medication administration (BCMA) systems to confirming the identity of the patient as well as confirming the range of medications that are needed to be administered.

 Develop alerts and notifications in EHR to remind clinical professionals about the following doses.

 Sustaining a Mindset of Security

 Permit individuals to report medication errors or near misses with no reprisal to look for possible opportunities for error prevention.

 Some of the interventions that need to be implemented include; Conducting pre-specified cycles of audits and reviews of medication administration practices in order to come up with potential revisions and adjustments.

 References

 ISMP—Institute for Safe Medication Practices (2020). Integrated ISMP Guidelines for the Standard Order Sets. ISMP. This document contain recommendations for the reduction of errors such as those involved in medication omissions.

 National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). (2020). NCC MERP Index for Classifying Categorised Medication Errors. NCC MERP. This index divides the errors and stresses on the omission errors.

 Bates, D. W. , & Gawande, A. A. Measuring the Quality of Care: Using Information Technology to Assess Performance [Electronic Version]. Journal of the American Medical Informatics Association: JAMIA 10(4), 323–326. Working to Enhance Safety through Information Technology. New Engl J Med 348, 2526–2534. This article highlights on the ways that organisational technology might be used to eliminate medication errors, with omission being among them.

 Classen D. C. , & Pestotnik S. L. (2002). Computerized physician order entry: Queries of a literature review. J Am Med Inform Assoc, 9(2), 195–204Extractor: Journal of the American Medical Informatics Association This review focuses on the effectiveness of computerised systems on decreasing medication administration errors.

 Summary

 Medication administration oversight or omission errors are one of the major problems in healthcare organization, affecting patients’ safety and quality of care. To rectify this issue, it means having efficiency strategies like; applying of technology, communication, training, and safety culture. Thus, such actions will help decrease the rate of omission errors and improve the healthcare stakeholders’ quality of the work.