A conversion factor is a numerical quantity used to multiple or divide when converting from one system of measurements to another. For example, when converting milligrams to grams, the milligrams is always divided by 1000 to get the final answer in grams. If someone had 35 milligrams of NaCl and wanted to know how much 35 milligrams of NaCl would be in grams, they would divide 35mg by 1000 to determine the number of grams. 35mg x 1g/1000mg= .035g. The mg would cancel leaving the final unit as grams. Conversion factors are especially critical when administering medicine to child, because children vary greatly in weight from an adult so children cannot accept the same dosage as an adult would. The less they weigh, the less dosage they can receive. If a child receive the dosage intended for an adult the child would experience an…
Any kind of error, whether it causes no harm to the patient or kills the patient, is still an error that needs to be reported and addressed. This collection of data begins with looking at the CPOE (electronic physician orders), Pyxis dispense history, eMAR, narcotic waste history (if a narcotic error), barcode scans, and the stage that the error occurred. These are all important data pieces to collect and analyze in order to pain the picture of what happened and why. The stages of where/when the error occurred are very important for identifying patient harm. Stage one is considered a prescribing error where the incorrect drug or dose is selected for a patient. This kind of error is also the cause of illegible handwriting and/or the misspelling of a drug with a similar name (Williams, 2007). Prescription errors make up for between 1-11% of all written prescriptions (Sanders & Esmail, 2003). Stage two is where dispensing errors occur. This is considered to be selection of the wrong product where usually there are look alike and sound alike drugs involved such as Losec and Lasix. Step three and four are the preparation and administering stages and the rates of these errors vary between 3.5% and 49% (NPSA, 2007). These stages are areas of high risk within nursing practice where nurses fail to verify important information such as drug, patient, dose, time, and route (Williams, 2007). IV drugs are suggested to be as high as 25% of medication errors in these stages (Bruce & Wong, 2001). Stage five is errors in monitoring outcome. Patients take certain drugs that require continuous monitoring to ensure the dosing is correct and there are no adverse…
Agency for Health Care Research and Quality (AHRQ). (2012). Computerized Provider Order Entry. Retrieved from…
Richard, I agree with you, it is a huge responsibility for unlicensed staffs to administer medication. As nurses, we received education and proper training and still make a lot of mistake. I cannot image an unlicensed personal administering medication. Where I work, we have medical assistant and I have to admit that some time, they have to work faster and harder than nurses. If in top of their duty and underpay, they have to give medication for patients, there is no question that there will be more medication administration…
Stock, MS, BSN, RN. Basic Pharmacology for Nurses. 13th ed. United States of America: Mosby, 2004.…
The most useful data for correcting errors in this prescription process is data that outlines where the majority of the errors occur. There are a wide variety of possibilities and errors that can occur in the prescription process, therefore having data that helps to pinpoint where most issues occur would be very helpful. Once it is understood where the majority of the errors occur, analysis can be done and solutions can be analyzed to fix the problem area(s). As seen on the Medication Errors – Error Reporting pie chart, a vast majority of medication errors can be traced to either administration or prescribing of the medication (Griffith). This means when process improving to reduce prescription errors, these two areas should be the initial…
As mentioned above, different strategies have been implemented to prevent the unfavorable effects of medical errors, particularly mistakes in medication administration. Because of medication errors, the patients’ mortality went up, which costs the U.S. healthcare systems billions of dollars yearly. It was also reported that every year, there are approximately 450 000 unfavorable medication circumstances of which 25 percent could have been prevented, that caused an injury to the patient. Therefore, other than the CDSS/CPOE implementation, the following systems were being used to aid in the improvement of the medication administration efficiency: intravenous infusion pumps with preprogrammed drug information, barcode-assisted medication administration…
This article explains in great detail the errors that many pharmacists make that contribute to the medication errors in and emergency department. The leading cause of pharmacists errors are in the charting that is done prior to dispersing medication. This article shares the enormous information in regards to the ways that pharmacists could do their job differently in order to keep the number of medication errors down.…
In the organization, when medication error occurred, we will immediately inform our nurse manager, team doctor in charged of the patient that is involved, patient and family members. When incident happened, there will be a need for close monitoring and watching out for serious side effect for the patient who is involved. After reporting incidents, the staff involved will have to…
Each year in the United States there are just over 450,000 reported medication errors, they are the sixth leading cause of death, as well as costing the health care industry roughly 3.8 billion dollars (Flanders & Clark, 2010). QSEN’s published mission statement is to, “Address the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work.” (2016). QSEN has seen the devastating effects that medication errors have had on the nursing profession and are continuously publishing refined guidance and evidence based best practices to better prevent…
A medication error is any avoidable event that may cause or lead to untimely medication use or patient harm; however, while the medication is still in control of the health care administer (Brock, 2006). 80 percent of the most severe medical errors can be interrelated communication between clinicians, primarily in handoffs. For example, a handoff is a medical error if information regarding an essential diagnostic test is not communicated carefully and properly between providers at shift change (Starme, 2015). However, the end result could be a detrimentally harmful delay in patient care.…
As a result of the literature and analysis, I learned that safe medication administration is one of the most important skills that a nurse can have. If a medication error occurs, it can have many ethical, social, economic and safety ramifications. The research presented has also allowed me to see that medication errors are more likely to occur in certain situations, such as a hectic and distracting workplace. The literature suggests that I should do the best that I can to avoid such situations by finding a quiet space and taking my time to attentively go over the required medications to prevent error.…
According to their research, 526,186 incidents occurred, with 16% of the incidents causing patient harm and 0.95% resulting in serious harm or death (Cousins et al. 2012). A U.S. study by the Institute of Medicine found that medication errors cause harm to approximately 1.5 million people and kill several thousand each year in the U.S. (Diamond, 2006). While not Canadian statistics, these values are a demonstration of the seriousness of drug errors. Medication errors can lead the patient and their family to become increasingly worried about the safety of their loved ones and about the quality of care they are receiving (Kim & Bates, 2012). The adverse effects of the drug could also result in a prolonged hospital visit, leading to further isolation from the patient’s normal routine and social life. In addition, the nurse who administered the medication would also face several social issues. Often a nurse who makes a medication error faces increased scrutiny from their peers; if the mistake is severe enough the nurse could face disciplinary action such as a suspension of their nursing license. This…
Among patient safety concerns, medication administration errors are preventable. For the purpose of this study, an medication error will be defined as any preventable event or deviation from the physician’s order that may cause or lead to inappropriate medication use or patient harm while the medicine is in the control of the nurse (National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), 2010). The definition was adopted from the National Coordinating Council for Medication Error Reporting and Prevention and altered to include, any deviation from the physician’s orders, to allow for error to be…
Technology in health care is growing substantially every single second of the day and becoming an essential for health care professionals. Technology has not only is made communication easier, but played a rather large role in preventing patient harm. Valerie J. Gooder Ph.D., RN reports that the Institute of Medicine in 1999 reported that “nearly a million patients each year are injured in hospitals in the United States due to error. Medication errors occur more often than other categories of preventable errors (19%), and most medication errors occurred during medication administration (34%) where they were more likely to directly impact the patient and cause harm.” (Gooder, 2011). Not long after looking at these percentages was the BCMA (Barcode…