Description
Group C Scenario: You work in a small (58-bed) busy rehab care facility, which has had an increase in medication errors, especially in the management of pain medications (increasing rehab stays, and costs, and increasing family complaints). Upon further investigation, it is found that patients are not receiving all the pain meds that are being ordered and documented, and it is suspected that a staff member is stealing the drugs for personal use or resale. Institute a plan to find the errors and increase medication accountability, without placing blame. How are all members of the IP team involved?
A powerpoint has been created (see attachment) based on the scenario and its contents has other necessary details. Below is a question that should be answered based on both the scenario and the powerpoint:
QUESTION: Which medication administration rights have been addressed by our methods to decrease medical errors, and is there any other methods you can think of to improve our situation?
Requirements:
• You are to answer the above question after viewing the scenario stated above as well as the powerpoint, you are also to demonstrate an excellent understanding of the topic.
• Content is well articulated, flows logically, and facilitates communication.
• Writing is original with limited use of direct quotes.
• Writing is supported by content from the nursing literature and other scholarly resources.
• Writing should offer substantial contributions which integrate peer comments and build on knowledge.
• All citations and references are properly formatted, the in-text citations should have pages of book/ journal/article where it was cited from.
• A minimum of 3 sources referenced in APA format and proper grammar, spelling, mechanics should be used throughout the assignment.
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Scenario 5
Yellow Group
The Situation
You work in a small (58-bed) busy rehab care facility, which has had an increase in medication errors,
especially in the management of pain medications (increasing rehab stays, and costs, and increasing family
complaints). Upon further investigation, it is found that patients are not receiving all the pain meds that are
being ordered and documented, and it is suspected that a staff member is stealing the drugs for personal use or
resale. Institute a plan to find the errors and increase medication accountability, without placing blame. How
are all members of the IP team involved?
Who is Who
➔
ANP (geriatrician) – writes the prescriptions. Has authority on which medications are distributed.
➔
BSN, RN (unit manager; strong patient care advocate) – oversees the employees. They are responsible the LPNs are properly
administering and documenting.
➔
PharmD – double check and prepare medication for administering.
➔
LPN (care provider, often passing meds- noticed increase in pain med use) – patient care provider.
➔
LPN is the final step in the administration process. They obtain the medication, administer it, and document the administration.
➔
The suspect or suspects are most likely LPN since they are the individuals documenting and not administering.
The Practice Setting
➔
Skilled Nursing Care Facility (SNCF)
◆
➔
Performs skilled nursing care.
Skilled Nursing Care
◆
Therapeutic and nursing care that can only be given under the supervision of professionals or
technical personnel. Given when skilled nursing or therapy is needed treat, manage, observe, and
evaluate care (SNF Care Coverage).
➔
The LPN is the one who most likely administers the medications and provides care while the BSN, RN
overlooks the LPN.
➔
Based off of the scenario, pain medications, most likely opioids, are being inappropriately documented.
It is unclear which regulations are in place.
The Plan to Find the Errors
★
Announcement board
○
★
Have nurses fill out an error reporting form
○
★
Report to the BSN RN each time it occurs
Turn in the form online to maintain a database
○
★
Includes the last fall and how many medication errors within the month
Make sure the forms are turned in and the BSN RN receives a copy
Continuing education programs
○
Nurses must attend quarterly classes based on what requires adjustments
Error Reporting Form
★
Patient impact or level of harm to patient
○
★
Patient information
○
★
Date of incident, what shift it happened on, and if it was done again
Primary type of medication error
○
★
Age, gender, number of medication the patient was taking
Incident information
○
★
From a “near miss” to a patient death
Whether it was an overdose, underdose, wrong medication, wrong patient, or wrong route
Phase of medication care process where error first occurred
○
Whether during dispensing, documenting, administering, or monitoring
Error Reporting Form Cont.
★
Primary and secondary personnel involved in error
○
★
If it was a misprint in prescription from the ANP, pharmacist, RN, or LPN
Medical effects of the error on patient
○
How did it affect the patient? Ex. respiratory distress, headache, excessive side effects,
change is BGL, cardiac arrest, GI Bleed, or death
★
Causes or reasons for error
○
★
Ex. medication name confusion, illegible writing, poor communication, or human error
Specific medications involved in the error
○
What drug was involved? Ex. vitamins, herbal medications, nutritional supplements,
prescription medications or OTC medications
The Plan to Increase Medication
Accountability
Each LPN is responsible for Medication Administration Cross Checks (MACC) for narcotic medication
administration and filling out narcotic documentation book
LPN
BSN RN
Draws up medication and verbalizes what
medication they have in hand : Drug, Reason,
Route, Patient
Answers back if there are any contraindications the
patient may have and patient allergies
If no contraindications or allergies, continue
Ask to state the Amount
State the drug concentration, mL to be administered
or number of tablets and show the vial to check what
is left in the vial or ampule
Double check the correct amount
Fill out narcotic documentation book
Witness narcotic documentation with LPN and if
there was any waste
The Plan to Increase Med
Accountability Cont.
➔
Biometrics, including fingerprint scanners, and pharmacy automation technologies minimize human
involvement and have been shown by evidence to decrease medical errors (UY, 2015).
➔
Electronic fingerprint signature:
◆
The med box could be changed to an electronic one (if it is not already)
◆
Fingerprints could be required for access to the med box
●
Fingerprint access would make it possible to keep track of who took what for which
patient
The Plan to Increase Med
Accountability Cont.
➔
The electronic med box would show you how much a specific patient needs and only let you take out
however many vials meets said dosage
◆
This would help keep track of unused meds in the med box and keep the nurse from taking more
than necessary
➔
When wasting, the electronic fingerprint med box would make you have another nurse witness by
fingerprint, to avoid signature forgery
The Plan to Increase Med
Accountability Cont.
➔
Fingerprinting witnesses
◆
The med box would ask how much was taken out of the med box (ie. how many vials does the
other nurse have left), the witness would answer and then fingerprint
◆
The med box would ask how much was given to the patient and the witness would type the
answer and fingerprint
◆
The med box would then ask how much is left in the syringe and the witness would type out the
answer and then fingerprint
➔
Both the witness and the nurse would then have to give their fingerprint to the electronic med box after
the waste was dropped in the machine
References
Friese, G. (2015). Quick Take: Strategies to reduce medication errors. EMS today 2015.
Pierson, S., Greene, S., Williams, C., Akers, R., Jonsson, M., & Carey, T. (2007). Preventing medications errors
in long-term care: results and evaluation of a large scale web-based error reporting system. Qual Saf
Health Care, 297-302.
SNF Care Coverage. (n.d.). Retrieved from https://www.medicare.gov/coverage/skilled-nursing-facility-snfcare.
Uy, R. C. Y., Kury, F. P., & Fontelo, P. A. (2015, November 5). The State and Trends of Barcode, RFID,
Biometric and Pharmacy Automation Technologies in US Hospitals. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765644/.
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