Medication Error
Medication error refers to failure in the process of medical
treatment that leads to the death of the patient (Ajazuddin, &
Saraf, 2012). A medication error is most common mal-practice is a health care
setting that leads to poor health outcomes of the patients (Weant, Bailey&
Baker, 2014).
Nursing staff found to be the most responsible for medication
administration error. In the current case of Ms D, the finest example of medication
error can be seen. Ms D was a 73 years old female, having ischemic heart
disease. She was admitted to hospital for aortic replacement and coronary
artery bypass surgery. Ms D was taking warfarin before the surgery ad the
intake of those medicines was ceased before the surgery. She was given fentanyl
infusion for pain recovery and ceased after two days of post operation.
Ms D was discharged from hospital after post-operation, and the
recommended used of warfarin was documented in the file. The clinicians did not
recommence the use of warfarin, and the nurse ignores to recheck the INR, and
verbally recommended the patient to change the medicine for pain relief.
Unfortunately, her guardians were not present at that time. The misuse of
medication leads to the death of Ms D. The loss of death is unbearable loss and
the extremist mal-practice in the health care setting. NSQSH standard 4
implement strategies to avoid such mistakes (Weant, Bailey& Baker, 2014).
Medication reconciliation is an important aspect of medication administration
and management process to ensure patient safety In health care. In the current
case, the significance of medication reconciliation can be seen in the form of
death of patients. The action 4.5 enforces the responsibility on nurse or
health care practitioner to take the best possible medication history (BPMH)
with the collaboration of parents (Mellish et a., 2015). It also
highlights the systematic process to record the patient oral intake of
medication and recording BPMH. A nurse should keep a record of MBPMH for
avoiding obnoxious consequences. At least two sources of information should be
considered to obtain or confirm the patients BPMH.
All the guidelines, procedures and policies should be followed for
with the collaboration of clinicians. The standard form for recording a history
of medication before admission or the discharge of the patient helps in
reducing the risk for mal-practices of medication administration (Weant, Bailey&
Baker, 2014).
Furthermore,
it also helps the patient to take the recommended medication at home. The
clinician feels feasibility in reconciling medication if the BPMH or record of
the medication is accessible to clinician. Action 4.6 recommend the timely
discrepancies in medication according to the severity of the patient medical
problem. In the above-mentioned case, the absence of a timely reconciliation of
medication leads to the death of the patient. The 4.6 action primarily focuses
on the rechecking of medicine order at the time of admission to after the 24
hours. During the episodes of care, the medication list is rechecked if the
list of medicine s accurately communicated or not (Cheragi
et al, 2013).
Lastly, at the time of discharge, the list of medication should be
rechecked if the old one has been prescribed or the new one has been added in
the form. Such precautions in healthcare can enhance the quality of life among
patients. As a registered nurse by taking action 4.5 and 4.6, the medication
error can be prevented. The previous researches of Australian health care
practices suggested that the medication error was very common mal-practice in
the nursing, but in a few recent years, the ratio of medication error has been
controlled by implantation of high legislation and ethical code (Weant, Bailey&
Baker, 2014). The situation will be improved n the upcoming years hopefully.
Ethical Principles
Ethics in health care are imperative to follow to provide person-centred
approach (Taylor, 2013). Ethical principals in medication impose some
responsibility to nurse and health care professional for not violating the
rights of humans. The code of ethics comprised of many principles, but here
beneficence and non-maleficence have been discussed. Beneficence refers to the
beneficial action to reduce the harm to the patient (Taylor, 2013). Beneficence
ensures the provision of health care services and medication carried out for
the benefit of the patient (Zolkefli, 2017). The ethics of beneficence entail
that all the health care practitioners the registered nurse, psychologists,
psychiatrist, physicians and other skilled staff member use their expertise and
adequate knowledge, to increase the safety of the patients (Taylor, 2013).
All the actions, action, management and intervention design should
enhance the quality of life among patients. According to the beneficence
principle, the patient-centred practices must be carried out to meet the needs,
want and desires of the patients (Weant, Bailey, & Baker, 2014). In the above case of Ms D, the loss of death
is unbearable. The action should be taken by the nurse to communicate the
clinician before giving the verbal recommendation to the patient for using
medication. The communication gap between registered nurse and clinician or
other staff member leads to obnoxious consequences (Bradley,
2017). Communication and care can bring positive results. The standard
nurse should recheck the standard form for ensuring which medication has been
replaced or reconcile. The patient parents should be there at the time of
discharge to take the recommendations regarding the care and medication of the
patients (Taylor, 2013).
Non-maleficence comprised of action to avoid the causation of the harm.
Literature recommended that due to mal-practice, communication gap, and other
careless mistakes of the health practitioner leads to the death of the patient
(Zolkefli, 2017). The registered nurse and another healthcare practitioner
should strive for reducing damage associated with the medication. As in the
current case, registered nurses should avoid giving instructions to the
patients without reading the prescription (Taylor, 2013). Small careless
mistakes lead to the death of the patients. The registered nurse should not
give the patient verbal instruction without authenticity (Zolkefli, 2017). The
results could have been different if the registered nurse follow the ethical
principles. The significance of parental involvement cannot be neglect, as they
should not give the patient unprescribed medication considering the severity of
illness.
Unfortunately, none of the above ethical principles has been
discussed in the current case. Therefore the undesirable results have been
achieved. The ethical code suggests that the patients should not get any kind
of emotional, physical, psychological or medical harm during the treatment (Donovan
2017). In the above case, all the ethics have been violated that spoils the
reputation of health care. The ethics should be given more attention in
training the health care staff, to avoid such mistake in the future. The recent
empirical data suggested that the implementation of ethical principals in the
health care setting found to highly correlated with the quality of life and
life expectancy of the patients (Taylor, 2013).
Legislation
The legislation of medication in Australia provides an in-depth
understanding of the legal use of medication administration (Kadivar et al.,
2017). The significance of the legislation in medication cannot be ignored, as
the quality of life, mortality and life expectancies of the patients primarily
depends upon such legislation. In a health care setting to enforce laws and
acts bring about peace and order to prevent the expected harmful effects
(Kadivar et al., 2017). The legislation is imperative inaccurate as well as
chronic cases to reduce the threat or harm of the patients. The major role of
the health care system is to provide the safety and security to the patient for
improving the life expectancy of the patients. In the mentioned case of Ms D,
the error in medication result in the death of the patient.
The careless mistake of the registered nurse, not to read the
prescription of the clinicians brings about obnoxious consequences (Collier 2013). Therefore to implement the legislation
in health care is imperative. The legislation imposes some roles and
responsibilities to health care practitioner and registered nurse to follow the
rules and regulation to avoid harmful effects. The administration of medication
comprised of who to mediate, the prescriber, the qualification of the
prescriber, time, cost, dose, finality and confidentiality. Drug poison and
substance control substance regulation Act 2017 defines the legislation
regarding administration, supply, dispense, and prescription of medication to
avoid disastrous results. The legislative schedule for fentanyl infusion, oxytocin
and paracetamol recommended that the licensed wholesalers should sell
medications and authorised practitioner and registered nurse should prescribe
the medicine. The unauthorised wholesaler and the health care practitioner can
bring about the disaster and distort the fabric of society. The federal
legislation of Australia recommended banning the unauthorised wholesaler and
the health care practitioner (Lipworth, & Kerridge, 2013).
The police must be informed if any unauthorised person is found in the medial
store or health care centres.
The legislation regarding medication storage also impose some rules
on registered nurses. The medicines should be stored in the hardcore wall and stud
or hollow block in drug cabinet. A medicine storage facility for the schedule
should be kept away from the access of the unauthorised people (Kadivar et al.,
2017). Practitioners employ lawfully can transfer the medicine from schedule 4
or 8 to the patients. Authorised nurses are allowed to administer the schedule
4 or 8 drugs to the patients, but not allowed to have unauthorised access to
such medication. The registered nurse should notify police or MPR if any drug
found to be misused or stolen. In case of any discrepancies have been noticed
in the storage and documentation, the registered nurse must inform MPR
only. If a person is found to use a
false prescription for using medication, again, the MPR must be intact.
Furthermore, if a person is suspected of using false pretence, A
schedule 4 or 8 poison police or MPR must be notified. This legislation helps
in controlling or reducing the mortality rates in the health care setting (Avasthi et al., 2013). The implementation of
the acts should be more strict in the health care setting to improve the safety
of the patient (Kadivar et al., 2017).