Introduction
Medication errors are common in the emergency department, particularly during cardiac and respiratory resuscitation cases. According to Institute for Safe Medication Practices (2011), medication errors during emergencies are more likely to cause injury and result in death than errors that occur outside the emergency department. Kiani et al. (2020) state that medication errors in health facilities are among the top causes of death in America, with nurses being responsible for most of the medication error cases. Emergency department nurses are often tasked with administering medication to patients in high-stress situations, and the potential for errors is greater due to the rapid pace of care (Rodziewicz et al., 2022). Common medication errors during resuscitation cases include incorrect drug, dose, route of administration, or timing of administration. Additionally, inadequate communication between the healthcare team members may lead to errors in administering medications and life-saving treatments. If information is not communicated properly or on time, there may be mistakes.
To minimize the possibility of medication errors in the Emergency Department, healthcare teams must ensure effective communication, the use of standard protocols, and careful monitoring of medications. Adherence to standardized protocols and guidelines can help mitigate the risk of errors by ensuring that all team members are aware of the medication orders and timing of administration. Hospital administrators and nurses can also incorporate technology to help nurses avoid medication errors by providing alerts when medications are about to expire or if incorrect dosages are entered. Additionally, double-checking medications before administration is important in preventing errors (Rodziewicz et al., 2022). Finally, nurses should keep a neat and organized workspace, including medication charts and other supplies. This will help to ensure that medications are easily accessible and that the right medication is given to the right patient.
Role of Leadership and Education in Mitigating Medication Errors
Leadership and education are essential to preventing medication errors in the emergency department, such as during cardiac and respiratory resuscitation cases. Leadership plays an important role in developing and implementing protocols, policies, and procedures and providing strategies to ensure that nurses are well-informed, trained, and competent in their roles. According to Kiani et al. (2020), educating nurses on the importance of medication safety and proper technique during resuscitation is key to preventing medication errors. Leaders should also provide resources and support to ensure that nurses have the information and training to make informed decisions. Additionally, leaders should strive to create an environment where nurses feel comfortable speaking up and seeking assistance if they are uncertain about a medication or procedure. Finally, leaders should strive to create a culture of safety and accountability, where nurses feel comfortable asking questions and voicing concerns without fear of repercussions.
Description
I encountered a situation involving a nurse’s medication error in an emergency department during a cardiac resuscitation case. The nurse had mistakenly administered an incorrect dose of epinephrine to a patient in cardiac arrest. As a result, the patient’s heart rate remained too low, and the patient was not responding to the medication. After further investigation, it was determined that the nurse had not properly read the medication label and had given the patient an incorrect dose of epinephrine. The error was rectified, and the patient was stabilized.
Feelings
I felt incredibly disheartened and frustrated in this situation. It is a nurse’s responsibility to ensure that they are giving their patients the correct dose of medication and that they are reading the labels correctly. The fact that an error occurred could have caused serious and irreparable harm to the patient, so I would be devastated and would strive to learn from the mistake in order to avoid making a similar error in the future.
Evaluation
Upon reflection, I realized that errors made by the nurses are mainly because they are under a great deal of pressure in the Emergency Department and are trying to act quickly to provide the best care for the patient. The medical team’s lack of coordination and communication also contributed to medication errors. It was clear that the nurse was not adequately trained to handle a cardiac or respiratory resuscitation case.
Analysis
The root causes of the medication errors included a lack of communication between the medical staff and insufficient training in handling cardiac or respiratory resuscitation cases. In order to prevent medication errors, the nursing staff needs to be given more time to accurately assess the patient and double-check any medications they are administering. It is also important that the staff are given instructions on the correct standard protocols that help reduce the risk of errors by providing directions on how to address the situation, reducing the need for nurses to make decisions on the fly. Additionally, standard protocols provide an additional layer of safety by providing standardized documentation and tracking of the medication process.
Conclusion
In conclusion, the nursing staff in the Emergency Department must be given the time and training they need to ensure that medication errors are prevented, especially in cardiac or respiratory resuscitation cases. Additionally, communication and coordination between the medical staff need to be improved to prevent medication errors in the future. This will help to ensure that the best care is provided to the patient and that any potential risks are minimized.
Action Plan
Goal 1: To provide nurses with the skills and knowledge necessary to recognize and prevent potential medication errors.
Objectives:
- To create and deliver an educational program focusing on the causes and prevention of medication errors;
- To develop a system for nurses to follow that encourages safe medication administration and patient monitoring;
- To provide nurses with the necessary resources and tools to identify and address medication errors accurately;
- To establish a process for nurses to report and document medication errors;
- To utilize case studies to demonstrate the impact of medication errors on patient safety;
- To implement a feedback and evaluation system to ensure that nurses are adequately informed and empowered to take the necessary steps to avoid and prevent medication errors.
Goal 2: To improve communication and coordination between the medical staff to prevent medication errors.
Objectives
- To develop a standardized system for medical staff to document medication administration and reconciliation;
- To develop and implement clear protocols for communication between medical staff members during shift changes;
- To establish an interdisciplinary team to review and evaluate medication errors and develop solutions to prevent them;
- To establish a system of regular meetings between medical staff to discuss any changes in medication administration protocols;
- To implement an electronic system for ordering, administering, and monitoring medications;
- To establish a system for tracking medication-related inquiries and complaints;
- To develop a system of rewards and recognition for nurses who successfully prevent medication errors.
References
Institute for Safe Medication Practices. (2011). Preventing medication errors during codes. Web.
Kiani, F., Salar, A., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13(1). Web.
Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2022). Medical error prevention. National Library of Medicine; StatPearls Publishing. Web.