Read the following two articles from the reference list below A) Brady et al (2009) & B)Donaldson (2002). Then complete the worksheet exercises.
Read the following two articles from the reference list below A) Brady et al (2009) & B)Donaldson (2002). Then complete the worksheet exercises.
A)
Brady A-M, Malone A-M Fleming Sc (2009) A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of nursing management 17 (6) 679-697http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2834.2009.00995.x/pdfB)
Donaldson L (2002) An organisation with a memory Clin Med JRCPL ;2:4527
You can use these other resources to help you:
NHS England (2016) NHS Outcomes Framework- Damain 5:- Treating and caring for people in a safe environment and protecting them from avoidable harm.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385749/NHS_Outcomes_Framework.pdf
NHS England (updated 2015) https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf
https://www.youtube.com/watch?v=zeldVu-3DpM
Please answer the following question:
Q 1. What constitutes an incident & when should an incident report be generated in practice?
Q 2. Why is it important to report patient safety incidents?
Q 3. What is the purpose of A Datix report, do you know what happens within your organisation/Trust to these reports?
Q 4. What constitutes a medication error & How can medication errors be avoided?
Q 5 Whose responsibility is it to ensure medication is administered currently in practice?
Q 6 Is there a time when verbal messages to administer a drug occur in practice?
Q 7 What is the procedure which needs to be followed if a verbal order is given?
Q. 8 What is your understanding of Royal pharmaceutical society & RCN (2019) guidance on administration of medicines in healthcare settings and what is the role of the student nurse in compliance with the guidance?
Q9 After reading the two articles A & B summariser their key messages.
9A)
9B)
Answer guide
Q 1. What constitutes an incident & when should an incident report be generated in practice?
Answers to include:
What: any incident that can be deemed to constitute a harm or potential harm to the patient/ visitor or staff involved. This can be designated as within a risk matrix of likelihood to have caused harm (risk management slides) against the potential severity of harm to someone. An example could be given i.e. when a wrong does of medication has been administered, an adverse reaction happen or a piece of equipment is faulty.
When: After doing and emergency interventions, it is expected to fill out a Datix as soon as practicable on the electronic hospital system.
Expectation is that childrens nurses treat and care for people in a safe environment and protecting them from avoidable harm.
Q 2. Why is it important to report patient safety incidents?
Answer to ensure harm free environments can be improved and that the organisation can learn from mistakes (organisation with a memory: Donaldson 2002)
Q 3. What is the purpose of A Datix report do you know what happens within your organisation/Trust to these reports?
Answer: report to your immediate supervisor for students this would be the mentor of the nurse in co-ordinating the shift. After doing and emergency interventions a written report needs to be generated as soon as practicable fill out a Datix electronic form. Usual time frame is within 48 hours of the incident.
Patient safety incident reporting must be managed and reported in accordance with local and national organisational policies and procedures (NHS England 2016).
Reports are then investigated and statements are gathered and a root cause analysis is undertaken by a lead investigator this is then fed back to the trust boards via organisational risk managers. This then creates an action plan to ensure learning is disseminated to all the trust areas about prevention of other incidents. This can constitute a change in policy re training to new equipment being purchased etc.
Q4. How can medication errors be avoided?
Answer to include: discussion around the Rights of medication management 5Rs minimum etc
Q5 Whos responsibility is it to ensure medication is administered currently in practice?
Answer should start with the registered nurse etc.
Q 6 is there a time when verbal messages to administer a drug occur in practice?
Answer In an emergency resus situation when a scribe is present in the room.
Q 7 What is the procedure which needs to be followed if a verbal order is given?
Answer After the scribe has recorded what was verbally prescribed the usual checking of the drug should still occur this includes, the patient, dose checks ( dilution if required), name of drug & allergies if known, route for administration and if the drug has been given before and what time the drug was been given and the effect the drug should then it should always be written up post event and signed for by those that had checked and administered the drugs.
Q. 8 What is your understanding of Royal Pharmaceutical Society (2019) guidance on administration of medicine in healthcare setting and what is the role of the student nurse in compliance with the guidance?
Answer should include
It also provides guidance for who can be involved with medication checking administration as well as delegation/supervision of the student nurses (NMC 2018 section 11 & RPS (2019).
Q9 After reading the two articles A & B summariser their key messages.
9A) the answer should resemble this abstract contents Brady et al (2009 p679) Contributory factors to nursing medication errors are manifold, and include both individual and systems issues.
These include medication reconciliation,
the types of drug distribution system,
the quality of prescriptions, and
This should certainly be discussed: deviation from procedures: including distractions during administration, excessive workloads, and nurses knowledge of medications.
The key messages regarding : Implications for nursing management should also be identified: With managers implementing strategies to reduce medication errors including: the establishment of reporting mechanisms at international and national levels to include the evaluation and audit of practice at a local level. The student might refer back to the Datix question.
Other areas to cover:
Systematic approaches to medication reconciliation can also reduce medication error signicantly.
Promoting consistency between health care professionals as to what constitutes medication error will contribute to increased accuracy and compliance in reporting of medication errors, thereby informing health care policies aimed at reducing the occurrence of medication errors.
Acquisition and maintenance of mathematical competency for nurses in practice is an important issue in the prevention of medication error.
The health care industry can benet from learning from other high-risk industries such as aviation in the prevention and management of systems errors (Brady et al 2009 p679).
It is interesting to note: why errors are not reported even though this is old research (1997) Nurses interpretation of errors has also been identied as an antecedent of their decision to report medication errors. Baker (1997, pp. 156157) identied that nurses categorize medication errors in six different ways which include:
(1) If its not my fault then it is not an error;
(2) If everybody knows then it is not an error;
(3) If you can put it right then it is not an error;
(4) If a patient has needs that are more urgent than the accurate administration of medication, then it is not an error;
(5) If it is a clerical error, then it is not an error; and
(6) If an irregularity is carried out to prevent something worse then is it not an error.
9B)
This article was a ground breaking surge in 2002 to ensure healthcare systems start to learn from clinical incidents it was based on serious events some of which involved medication errors this identified for the first time the significance of systems errors and how a single medication error was a failure in the whole system and not just down to one individual. The students should pick this up as significant in a change process where organisations can learn from failures and by doing shift the mean of quality of care provided to all. To enhance shared good practice. This complies to clinical governance and quality medication errors where considered a large and mostly underreported event which was significantly impacting avoidable mortalities and morbidity in patients. It also points to the way the NHS is responding to adverse events and near misses! A system of reporting recording and analysing Root cause analysis could be discussed here and learning from errors in a non blame culture should be discussed.
The student should also identify that it is not just medication errors but equipment errors/failures which need to be reported. This had a significant effect in the current incidents this student was involved with.
The student might also discuss the improvements in labelling/storage of similar named drugs to avoid error occurrence.
Reference and get student to read:
Brady A-M, Malone A-M Fleming Sc (2009) A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of nursing management 17 (6) 679-697
Donaldson L (2002) An organisation with a memory Clin Med JRCPL ;2:4527
NHS England (2016) NHS Outcomes Framework- Damain 5:- Treating and caring for people in a safe environment and protecting them from avoidable harm. www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-5/
We can give student thisWeThe three Cs are defined as:
collecting
checking
communicating
Step 1 Collecting (basic reconciliation)
The collecting step involves taking a medication history and collecting other relevant information about the childs or young persons medicines. This information may come from a range of different sources (some potentially more reliable than others). For example:
a computer print-out from a GP clinical records system the tear-off side of a childs or young persons GP repeat prescription slip verbal information from the child or young person, their family, or a carer medical notes from a childs or young persons previous admission or discharge letter/prescription from hospital community pharmacist patient medication records childs or young person s own medications that may have been bought in with them at the time of admission emergency care summary record (ECS) clinic letters
The medication history should be collected from the most recent and reliable source. Where possible, information should be cross-checked and verified with another source which can include the parent or carer. The person recording the information should always record the date that the information was obtained and the source of the information. Where there appears to be a discrepancy between what the child or young person is currently prescribed, and what the child or young person is actually taking, this should be recorded too. The reasons for any variation should be noted if these can be established.
67Chapter 5: Medicines reconciliation and transcribing
Step 2 CheckingThe checking step involves ensuring that the medicines and doses that are now prescribed for the child or young person are correct. This does not mean that they will be identical to those documented during the basic reconciliation process. For example, a doctor now responsible for the child or young person may make some intentional changes to their medicines. Any discrepancies will need to be resolved in the final step of the process.
Step 3 Communicating (full medicines reconciliation)
Communicating is the final step in the process, where any changes that have been made to the childs or young persons prescription are documented and dated, ready to be communicated to the next person responsible for the medicines management care of that child or young person. Examples might include:
when a medicine has been stopped, and for what reason (including topical preparations) when a medicine has been withheld for a period of time when a medicine has been started, and for what reason the intended duration of treatment (e.g. for antibiotics or steroids especially if it is a decreasing dose) when a dose has been changed, and for what reason when the route of the medicine has been changed, and for what reason when the frequency of the dose has changed, and for what reason
