The Story Of Josie King Health And Social Care Essay

The Story Of Josie King Health And hearty C atomic number 18 EssayThe story of Josie King is one that shook the infirmary wellness flush frame in 2001. Josie King was an 18 month-old that died from complications of word at Johns Hopkins Medical Center. Josie was origin eithery admitted to the hospital with second and third period burns over 60 pct of her body. During c atomic number 18, Josie had received a deadly dose of methadone after which she died as a result of a cardiac arrest. As a result of this sentinel example, the Kings were awarded a closing which they refused. Josies m new(prenominal) wharf wanted everyone to know what happened to her baby. Sorrel King has pen an inspiring memoir Josies Story and has created a patient- synthetic rubber program at Hopkins in add-on to a foundation devoted to reducing checkup checkup slanderdoings. Sorrel King now advocates for patient and families minted by medical errors, and aloneow lectures to medical professionals c ountrywide. (www.josieking.org.)Medical errors accept and continue to be an enormous puzzle in health care. Patients die from the equipment casualty do doses or wrong dosage, or perhaps an infection that could have been prevent with better hygiene practices. More attention was limitd on the issue of medical errors in 2000 when the Institute of Medicine made available the well-known name title To Err is Human Building a Safer Health System. The report enter evidence of an estimated 44,000 people and as umpteen as 98,000 people anxious(p) in hospitals from medical errors each year in the United States (IOM, 1999). Of the some(prenominal) medical errors, medicament errors happen to be one that foundation not be overemphasized. music use have been found to account for at least 20 percent of inauspicious events in patients in hospitals. come to the fore of every hundred practice of medicine edicts, in that respect is an occurrence of five adverse drug events (Tam, 200 5).Malpractice claims due to adverse drug events can have prejudicious effects on the hospital and the health care providers. The hospital and health care providers can have their reputation damaged, thousands of dollars are spent for the losses, at that place is time lost from guide, not to mention the emotional stress snarly (Rothschild et. al, 2002). The cost of preventable medicine errors has been estimated between 17 and 29 cardinal dollars annu onlyy (Strohecker, 2003). As such, due to these alarming statistics, this paper focuses on well-nigh of the potential risks of medical specialty errors, and some recommended interventions that can be implemented to function curb the incidence of medicament errors.What is a medication error?A medication error is defined as any preventable event that may cause or curb to inappropriate medication or patient harm bit the medication is in the control of the health care professional, patient, or consumer (Oren, 2003). The term s adverse drug events and medication errors though used interchangeably do not necessarily mean the same(p) thing. An adverse drug event is an undesirable reaction after a drug brass instrument that is not necessarily caused by the drug. Adverse drug events admit adverse drug reactions and medication errors. medicament errors may lead to actual or potential adverse events. The potential adverse events are frequently 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).Potential Risks of Medication ErrorsMany of the factors leading to medication error are unfortunately human related (Etchells, et. al, 2008). A survey of 983 nurses working in acute care hospitals reported that among the umpteen factors that would contribute to medical errors, illegible hand written prescriptions, distraction from the environment, exhaustion and stress happened to be the to the highest degree weighted (Mayo Duncan, 2004). A sight by Hodgkinson et.al that sought strategies to stamp down medication errors cited the most common reason of medication error was due to the lack of drug information by the multidisciplinary team (2006). Inexperience and or lack of knowledge of the drug could lead to the doc ordering the wrong dose, the pharmacist incorrectly mixing the medication with the just c erstwhilentration, and the nurse administering the medication with the wrong r forthe such as giving an intramuscular shooter instead of subcutaneously (Etchells, et. al, 2008).While human error is very master(prenominal) to consider, it is equally important to analyze the context in which errors can occur such as the clinical environment and patient population. The type of clinical setting in a hospital can be more prone to medication errors than opposites due to the patient population with respect to the acerbity of their illness, and number and type of medi cations needed to be administered. comminuted care units for example, dispose to be at a higher risk for medication errors. Critical care units provide for very sick patients who need to be tended to(p) to without delay, may require consults from various providers, and receive twice as numerous 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 account for 78 percent of solemn 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 keen 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. previous(a) ad ult populations, on the other hand, take many prescription medications for their inveterate 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 deviate the safety of medication administration involves medication reconciliation. When patients list of home medications and allergies are not self-collected upon admission, a medication error can occur when a medication world taken regularly at home is not move 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 discha rged from the hospital. At measure there may be an oversight on the part of the prescribing physicians where brand and generic medication label are concerned. A physician may also duplicate order a medication that the patient may already be fetching 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 get rid of the paper documentation but the passageway is not that complete. Many hospitals motionlessness 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 take care correctly. American Health Association News mentions a study discussed in the Joint Commission Journal on Quality and Patient Safety, medication errors that were reported to the national database 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. Most 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 healthcare organizations can use as a reference (AHA News, 2007)Medication Error Risk Reduction StrategiesIn addition to the modified handed-down 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 trump practice procedures for medication administration designed by the California Nursing Outcomes Coalition (CalNOC) importantly ameliorate accuracy (2010). In this study, participating hospitals showed an 80.5 percent improvement in fond regard to CalNOC best practices and an 81.4 percent score for combined administration accuracy and best practice improvements. The CalNOC six best practices include compare medication to medical record, keep medication label until administration, check two forms of patient naming, instantaneously record medication administration in the chart, explain the medication to the patient, and decrease distractions and disruptions during the administration process (ACCN, 2010).Another technological invention to help narrow medication errors are the smart infusion pumps. These smart pumps have integral danger alerts, clinical calculators, and drug libraries including information on the standardized concentrations of unremarkably used drugs. Though smart pumps have been designed to prevent mistakes, it still works for high aler t intravenous medications. In cases where the smart pumps are not used appropriately, its purpose is not served. In a controlled running play study of smart infusion pumps, nurses were found to customly 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 enjoin (Rothschild et.al, 2005). Smart pumps can work exceptionally and prevent errors if alerts are paid attention to used appropriately.The calculating machineized physician order entry (CPOE) system is another 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 match accuracy of writing orders. Most of these CPOE 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 slide down in the rates of medication errors (2003).A study at the Brigham and Womens infirmary 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 seize some promise as an intervention to improve patient safety but would require further data of the benefits of costs b efore implementation. cadence label is another technological intervention that has been shown to decrease the rate of medication administration errors. Bar coding can alienate the possibility of nurses administrating medications without having a enter order. With restriction coding, each time a physician ordered a medication, the order is automatically transmitted to the pharmacy where a crotchety 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 wherefore 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 personal matters hospital led the way in 1999 instituting a national bar coding program. Within a year of initiation the VA hosp ital documented a 24 percent decrease in the rate of medication-administration errors (Wright et. al, 2005). Although the supreme goal is to protect patients, bar coding could also save hospitals tons of money. The average adverse event costs extra hospital old age 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 research can show that the benefits outweigh 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 needed 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 incl uding over the counter drugs. This routine has been found to reduce medication duplication and avoid the effects of contraindication while 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 behind 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 wildness 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 majority of errors can be attributed to system failures made worse by the increasing complexity of patient care. A medication error can cause devastating results, threaten p atients lives, and affect a providers confidence and job security. Hospitals also tend loose separate of money in malpractice law suits. The wide range of pharmaceutical 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 into 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.