The Story Of Josie King Health And Social Care Essay

The Story Of Josie exponent Health And Social C are EssayThe story of Josie exponent is one that shook the hospital health compassionate system in 2001. Josie King was an 18 month-old that died from complications of treatment at Johns Hopkins Medical Center. Josie was originally admitted to the hospital with assist and third degree burns over 60 percent of her body. During trouble, Josie had received a lethal dose of methadone after which she died as a provide of a cardiac arrest. As a result of this sentinel event, the Kings were awarded a settlement which they ref put ond. Josies mother Sorrel wanted e genuinelyone to know what happened to her baby. Sorrel King has indite an inspiring memoir Josies Story and has created a patient-safety program at Hopkins in addition to a foundation devoted to reducing medical exam errors. Sorrel King now advocates for patient and families affected by medical errors, and provide lectures to medical professionals countrywide. (www.josieking .org.)Medical errors have and continue to be an enormous problem in health care. Patients die from the wrong do drugs or wrong dosage, or perhaps an infection that could have been prevent with better hygiene practices. More attention was pose on the issue of medical errors in 2000 when the Institute of Medicine made available the well-known report titled To Err is Human Building a Safer Health System. The report documented evidence of an estimated 44,000 people and as mevery as 98,000 people dying in hospitals from medical errors each year in the United States (IOM, 1999). Of the many medical errors, medicine errors happen to be one that can non be overemphasized. Medication use have been found to card for at least 20 percent of obstinate events in patients in hospitals. Out of every hundred medication orders, there is an occurrence of five unfavourable drug events (Tam, 2005).Malpractice claims due to adverse drug events can have negative effects on the hospital and the healt h care providers. The hospital and health care providers can have their reputation damaged, thousands of dollars are spent for the losses, there is time lost from work, not to mention the emotional stress involved (Rothschild et. al, 2002). The price of preventable medication errors has been estimated between 17 and 29 billion dollars annually (Strohecker, 2003). As such, due to these alarming statistics, this paper focuses on almost of the potential endangerments of medication errors, and some recommended interventions that can be implemented to help oneself curb the incidence of medication errors.What is a medication error?A medication error is defined as any preventable event that whitethorn cause or lead to inappropriate medication or patient harm while the medication is in the control of the health care professional, patient, or consumer (Oren, 2003). The terms adverse drug events and medication errors though used interchangeably do not necessarily imagine the same thing. An adverse drug event is an undesirable reaction after a drug administration that is not necessarily caused by the drug. Adverse drug events include adverse drug reactions and medication errors. Medication errors may lead to actual or potential adverse events. The potential adverse events are oft termed near misses. For example, if a medication overdose is administered accidentally, it would be a medication error and not described as an adverse drug reaction (Oren, 2003). electromotive force Risks of Medication ErrorsMany of the factors leading to medication error are unfortunately human related (Etchells, et. al, 2008). A survey of 983 sucks working in acute care hospitals reported that among the many factors that would contribute to medical errors, illegible hand create verbally prescriptions, distraction from the environment, exhaustion and stress happened to be the most weighted (Mayo Duncan, 2004). A cogitation by Hodgkinson et.al that sought strategies to reduce medication errors cited the most common reason of medication error was due to the lack of drug information by the multidisciplinary aggroup (2006). Inexperience and or lack of knowledge of the drug could lead to the physician say the wrong dose, the pharmacist incorrectly mixing the medication with the righteousness concentration, and the nurse administering the medication with the wrong route such as giving an intramuscular injection instead of subcutaneously (Etchells, et. al, 2008).While human error is very historic to consider, it is equally important to analyze the context in which errors can occur such as the clinical environment and patient population. The character reference of clinical mount in a hospital can be more prone to medication errors than others due to the patient population with respect to the severity of their illness, and number and type of medications needed to be administered. Critical care units for example, angle to be at a higher risk for medication errors. Critical care units provide for very sick patients who need to be attended to without delay, may require consults from various providers, and receive twice as many medications as compared to patients on general medical floors. Patients in intensive care experience an average of 1.7 medical errors each day. Medication errors are the most common type or error and greenback for 78 percent of serious medical errors in critical care (Camire et. al, 2009).In addition to the patients in critical care, pediatrics and the elderly also tend to be at high risk for medication errors since there require many medications when sick. Pediatric patients in particular tend to be very streake-ass to most medications hence the need to calculate most of their medication dosages by weight (King, 2003). The least miscalculation could lead to an adverse drug event. Older prominent populations, on the other hand, take many prescription medications for their chronic illnesses which need scrutiny to avoid contraindications (ANJ, 2009). However, regardless of whether the patient may be at risk of experiencing a medication error or not, all medication administration must ideally follow the seven rights which include the right patient, right medication, right dose, right time, right route, right reason, and right documentation (Schaeffer, 2009).Another factor which may influence the safety of medication administration involves medication reconciliation. When patients list of root word medications and allergies are not collected upon admission, a medication error can occur when a medication being taken regularly at internal is not continued during the hospital stay. If the patients medication reconciliation is not complete, the physician would not have full knowledge of the medications that the patients would need to be restarted on after being transferred or discharged from the hospital. At times there may be an oversight on the part of the prescribing physicians where brand and gene ric medication name calling are concerned. A physician may also duplicate order a medication that the patient may already be taking at home, and at times order an incorrect dosage (Landro, 2006).In recent times, there have been technological influences in health care, where there has been an effort to take down rid of the paper documentation but the transition is not that complete. Many hospitals still document on paper and still creating the risk of medication errors by the use of error prone medication abbreviations. During transcription of written orders, the use of abbreviations can cause errors if not interpreted correctly. American Health Association intelligence service mentions a study discussed in the Joint Commission Journal on Quality and Patient Safety, medication errors that were reported to the national entropybase made up 5 percent of all errors that occurred as a result of incorrect interpretation of abbreviations used during prescribing (2007). In this same study , an analysis of 30,000 abbreviations related- medication errors reported to the United States Pharmacopeias database was made. intimately of the errors consisting 81 percent were made during the writing of prescriptions. The abbreviation QD used in place of once daily was found to have caused more errors 43.1 percent than any other abbreviation. The Joint Commission has a national safety goals report that include a do not use list of abbreviations that hospitals and other health care organizations can use as a reference (AHA News, 2007)Medication Error Risk Reduction StrategiesIn addition to the modified traditional seven rights for medication administration, hospitals are instituting additional evidence-based practices. According to an article in the ACCN monthly publication, the implementation of six best practice procedures for medication administration designed by the atomic number 20 Nursing Outcomes Coalition (CalNOC) significantly improved accuracy (2010). In this study, p articipating hospitals showed an 80.5 percent improvement in adherence to CalNOC best practices and an 81.4 percent score for unite administration accuracy and best practice improvements. The CalNOC six best practices include compare medication to medical record, keep medication labeled until administration, check both forms of patient identification, immediately record medication administration in the chart, explain the medication to the patient, and minimize distractions and disruptions during the administration process (ACCN, 2010).Another technological invention to help reduce medication errors are the smart infusion pumps. These smart pumps have built-in danger alerts, clinical calculators, and drug libraries including information on the standardized concentrations of commonly used drugs. Though smart pumps have been designed to prevent mistakes, it only works for high alert intravenous medications. In cases where the smart pumps are not used appropriately, its purpose is not served. In a controlled trial study of smart infusion pumps, nurses were found to routinely ignore danger alerts and drug libraries as much as 25 percent of the time, sometimes administrating medications such as propofol, insulin, and heparin at rates 10 times as high as those ordered (Rothschild et.al, 2005). Smart pumps can work exceptionally and prevent errors if alerts are paid attention to used appropriately.The computerized physician order entry (CPOE) system is another(prenominal) technology that has been found to significantly decrease the danger of illegible handwritten orders and the need for transcription. According to Bates et. al, out of the approximately 28 percent of preventable adverse drug events are associated with medication errors, 56 percent occurred during prescribing (Bates, et. al, 1998).The computerized physician order entry (CPOE), computer based system where all orders are electronically written helps to ensure accuracy of writing orders. Most of these CP OE are accompanied by a Clinical Decision Support System (CDSS) which provides automatic alert to prescriber on drugs or doses that are contraindicated with the patients age, allergies, condition, and or diagnosis. Review of a systematic study by Kaushal et. al on the effects of CPOE with CDSS showed a considerable decline in the rates of medication errors (2003).A study at the Brigham and Womens Hospital in Boston on the effect of CPOE on prevention of serious medication errors showed that the use of the CPOE system caught on to half the possible errors that may have lead to deleterious effects. The study showed a reduction in all the stages of the process from ordering to dispensing to administration (Bates et.al, 1998). CPOE therefore proven to hold some promise as an intervention to improve patient safety but would require further data of the benefits of costs before implementation.Bar coding is another technological intervention that has been shown to decrease the rate of medic ation administration errors. Bar coding can cede the possibility of nurses administrating medications without having a documented order. With bar coding, each time a physician ordered a medication, the order is automatically transmitted to the pharmacy where a unique bar code is generated. After verification of the order by the pharmacist, the labeled medications are sent to the floor/unit. The nurses who have to administer the medication would then(prenominal) have to scan the bar code on the patient identification band against the labels on the medications for comparison.Bar coding has shown to reduce medication errors by more than 50 percent, thus preventing preventable adverse drug events (Wright et.al, 2005). The Veterans Affairs hospital led the way in 1999 instituting a national bar coding program. at heart a year of initiation the VA hospital documented a 24 percent decrease in the rate of medication-administration errors (Wright et. al, 2005). Although the ultimate goal is to protect patients, bar coding could also save hospitals lots of money. The average adverse event costs extra hospital days and additional services, not to mention the cost of litigation. Like every other measure there would be disadvantages for using bar coding, but once more investigate can show that the benefits surpass the costs, more hospitals can join the increasing number of institutions that have embraced this technology.With medication errors responsible for many lost lives yearly, new national patient-safety standards require hospitals to have a mandatory formal medication reconciliation process for every patient admitted into the hospital. Medication reconciliation would take effect during the patients admission process and involves the recording of a patients allergies and thorough collection of all the patients home medications including over the counter drugs. This routine has been found to reduce medication duplication and avoid the effects of contraindication w hile the patients are hospitalized. This also aids the physicians on what medications to discharge the patient with. During the medication reconciliation process the need to educate the patients and their families is also import. Patients and families have to understand the rationale rear end keeping handy a list of all their medications and being able to provide the list especially in emergent situations (Landro, 2006).SummaryThis paper has reviewed research on medication errors in hospitals with an emphasis on the prevalence, risk factors, and strategies to prevent errors from occurring. Although the immediate cause of medication errors is often as the result of human error, the bulk of errors can be attributed to system failures made worse by the increasing complexity of patient care. A medication error can cause desolate results, threaten patients lives, and affect a providers confidence and job security. Hospitals also tend loose lots of money in malpractice law suits. The wi de range of pharmaceutic products and dramatically changing technology adds to the complex situation. Many strategies including the CPOE and CDSS, smart pumps, and bar coding among other strategies have already been implemented by few hospitals. look shows that these strategies that have been implemented targeting the reduction of medication errors have been found to be promising. However, due to the complexity of patient care, both human and technological influence may be able to control but never be able to completely put to death medication errors.