Make a meaningful response to a minimum of 3 of your colleagues in the discussion group. Start the response with the name of the person to whom you are responding. A meaningful response means you maintain professionalism, you respect the ideas and opinions of other in the discussion group, and that you reflect on the ideas presented and provide substantial input or ideas in response, not say “Wow, that’s interesting” and leave it at that. Illustrate that you did the assigned reading by applying the information from the readings. 

1. Respond to HC 

I believe if an error has occurred it should immediately be reported to the patient’s family. There was an error a few months ago were a baby got another baby’s breastmilk. The nurse had two bottles on the desk so she could scan off the breastmilk and before she could scan it a tech grabbed the breast milk bottle when she meant to grab the formula bottle and fed it to the baby who was getting formula. They baby only got like 5-10mL before the nurse realized the tech grabbed the wrong bottle, but you still have to notify the provider, the TM, the patient’s family, and the mom whose breastmilk it was because she has to go get blood drawn to test for any potential exposures to the baby who received the breastmilk. In the end everything was okay and the baby was fine, mom’s lab work was all fine but it’s still something you never want to happen. There was really nothing the nurse could have done differently in that situation, we don’t have computers in the rooms by the babies in the NACU so there’s no where else to scan the milk besides the nurse’s station. The only thing that could have went different is the nurse could have not left the breast milk bottle unattended, but she was going to get that baby to feed it so she could scan the baby’s arm band then scan the milk. And the tech should have double checked she had the correct bottle before she started feeding the baby, which you should do every time. I think the person who made the error should be the one to tell the family so they can answer any questions they may have. In this case both families were very understanding.

Hasan Dirik and associates did a study to investigate if nurses can identify and will report medication errors and he found that the nurses could almost always identify the errors but they were very reluctant to report the errors. He also found the main reason nurses did not want to report errors was because of fear of the consequences. He concluded if you create an environment were errors are supported and not punished then nurses are more likely to report medication errors (Dirik, 2019).

The Ethics Committee of Iran University of Medical Sciences approved a study that looked at factors affecting error communication in ICUs. They found the factors fell into 4 main categories: the culture of error communication, consequences of errors for nurses, consequences of errors for patients, and ethical and professional characteristics (Ghezeljeh, 2019). They concluded nurses will weigh the consequences of these 4 factors then decide if they will report the incidence. They concluded they way to promote reporting of errors is to create a safe reporting environment that focuses on solutions rather than consequences (Ghezeljeh, 2019).

References:

Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of clinical nursing, 28(5-6), 931–938. https://doi.org/10.1111/jocn.14716Links to an external site.

Ghezeljeh, T. N., Farahani, M. A., & Ladani, F. K. (2021). Factors affecting nursing error communication in intensive care units: A qualitative study. Nursing ethics, 28(1), 131–144. https://doi.org/10.1177/0969733020952100

2. Respond to SJ

I agree that any error should be immediately disclosed to the patients and their families. Doing the right thing and disclosing this information to the patient and families fall under the code of ethics of nursing. Patients and families are less likely to sue when they are told the truth and healthcare providers are being honest. Providing a thorough explanation of why and how the error occurred allow the patients their families the time to ask questions and provide insight on how the error may be prevented in the future.

Medication administration errors are a critical patient safety issue. Nurses are often responsible for administering medication to patients, thus their perception of the causes of errors can provide valuable guidance for the development of interventions aimed to mitigate errors (Schroers et al., 2021). Recently I ordered an incorrect medication for a patient’s first pump refill. The patient had Morphine in her intrathecal pump. At one time, the doctor was going to switch the patient over to Hydromorphone, but that did not happen. When the patient presented for her pump refill, the medication I had to do the refill with was Hydromorphone and not Morphine. The error was immediately noted when I began interviewing the patient. The visit was stopped at that moment, the patient and her sister were notified of the error and explained how the wrong medication was ordered. The patient rescheduled her appointment for the following week. I ordered the correct medication and took my time during the refill appointment to show and reassure the patient that the correct medication had been reordered. I also do a time-out prior to the refill procedure with another staff member. The patient was again reassured we had the correct medication. No harm was done to this patient as I was able to catch the ordering error before proceeding further.

Medication errors are classified based on multifaceted criteria and there is a need to standardize the recommendations and make them a central goal all over the globe for the best practice. Nurses are the frontlines of clinical settings and are encouraged to be the one integrated body to prevent the occurrence of errors (Alrabadi et al., 2021). Nurses are the heart of the clinical setting. Providing education and training on the reporting of medication errors without retaliation is crucial to open and honest communication with patients and their families when errors occur.

References

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021, January 6). Medication errors: A focus on nursing practice. OUP Academic. Retrieved November 12, 2022, from https://academic.oup.com/jphsr/article/12/1/78/6065944?login=false

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

3. Respond to MB

Error disclosure is not only our legal, but our ethical obligation. Furthermore, disclosure of errors leads to prevention of these errors recurring. Error disclosure is complicated enough when we disclose a medical error to our superiors and the agency for which we work, but it becomes much more complicated when we disclose those errors to the patients they affected. Informing the patient of the error is an absolute necessity if harm is caused or there could potentially be harm caused by the error. Additionally, studies have shown that patients are less likely to sue if the care team fully discloses the error made and makes a sincere apology.

When I was a new nurse, I accidentally forgot to halve a dose of a medication. It was an oral tablet. I had followed all the procedures—identified my patient and scanned all the medications she was receiving. I relied on the scan to do my five rights of administration. This should never be a substitute, only a supplement. And I was talking to the patient at the same time—not giving my full attention to administering the medications. The only reason I knew I had made the error was because the medication was a controlled substance, and when I logged in the Pyxis it showed that I had to waste that medication. I don’t even remember what the specific medication was, but it was either a sedative or a psych medication. I was so ashamed. I immediately told the charge nurse and we talked about it, and the importance of disclosing errors even to patients. With the support of my charge nurse, I wrote an IR, informed the provider, and got the courage to inform the patient. No harm was caused, and the potential harm was extremely mild (the patient was a little sleepier than she should have been), but the patient was extremely grateful that I had disclosed the error to her—even if it was seemingly small. Since then, I developed a habit of writing “1/2” or “1/4” on medication labels as soon as I pull them from the Pyxis—something I still do today. I would not have had this error disclosure go any differently—I believe I did everything I should have with the help of my colleague.

I am extremely grateful to have worked at a supportive learning hospital with supportive management and experienced positive role models such as the charge nurse who helped me that night. The support I received promotes both patient and nurse well-being. This is the “just culture” that Moffatt-Bruce et al. (2016) endorse in their article. Ghezeljeh et al. (2020) discuss factors that affect nursing error communication, one of those factors being a “culture of error communication” in which “error communication organizational atmosphere, clarity of error communication processes and guidelines, managerial support for nurses, and learning organization” (p. 134) are all present. When it comes to responsibility of error disclosure, I think it depends on the error and the amount of harm caused to the patient. The individual who made the error should lead the disclosure with the support of their superiors. Depending on the severity and timing of the error, hospital representatives at a higher level should lead the disclosure, but the one who made the error should be present and be a part of the disclosure (e.g. the death of a patient).

Ghezeljeh, T. N., Farahani, M. A., & Ladani, F. K. (2020). Factors affecting nursing error communication in Intensive Care Units: A qualitative study. Nursing Ethics, 28(1), 131–144. https://doi.org/10.1177/0969733020952100

Moffatt-Bruce, S. D., Ferdinand, F. D., & Fann, J. I. (2016). Patient safety: Disclosure of medical errors and risk mitigation. The Annals of Thoracic Surgery, 102(2), 358–362. https://doi.org/10.1016/j.athoracsur.2016.06.033