Safeguards to Prevent Medication Administration Errors in The National Health Service

Table of Contents

Selection of an area of practice that has transformed the role of the nurse

Identification of the length of time since last practice including rationale for selected area of practice

Impetus behind the transformation

Benefits and challenges for the nurse, care delivery, and implications for patient care

Bibliography

Selection of an area of practice that has transformed the role of the nurse

The area that has transformed the role of the nurse is the use of Automated Dispensing Cabinets (ADC) which is a decentralised medication distribution system that offers a computer controlled dispensing, storage as well as the tracking of medication at the care point in the patient care units. There are a number of benefits associated with ADC as it increases the nurses access to the drugs in the in-patient care areas and also aids in facilitating the administration of medication in a timely and accurate manner. Further, it also allows for the control of drugs and substances through the electronic tracking. To improve the inventory control, the stocking as well as distribution of the medications are tracked.

Identification of the length of time since last practice including rationale for selected area of practice

I have been working with the NHS in various areas and is currently working with older adult mental health patients. I currently work in the inpatient psychiatric assessment unit (NHS). The rationale for the selected area is based on the existing research on psychiatric medication errors. Data regarding adverse drug events (ADEs) associated with psychotropic medication are mostly derived from the ADE-reporting databases, parts of larger studies on general medical-surgical and data from non-psychiatric settings such as ambulatory clinics and nursing homes. Recent research undertaken by the Food and Drug Administration (FDA) reported that there were nearly 7,000 deaths each year from adverse drug reactions (ADRs) including 848 deaths (representing 12.3 per cent) arising due to psychotropic medications errors (Chyka 2000, p. 122). Other data have also been derived from large studies that make use of prospective cohorts together with active detection methods; with research indicating that active detection approaches lead to the identification of higher rates of drug errors as compared to spontaneous reporting. An 18-month study undertaken in tertiary care facility found that the use of computerised monitoring lead to the identification of high drug error incidences (Classen et al. 1991, p. 2847).

Another study that made use of many active detection approaches such as daily chart review amongst others, found that there were 6.5 ADE events in every 100 patients admitted; indicating that nearly 7 per cent of the ADEs resulted from errors in the psychotropic medication (Bates, Leape, and Petrycki 1993, p. 289). Another study undertaken noted that errors in the psychotropic drugs administration accounted for nearly 0.41 per cent of the serious medication errors (Bates et al. 1998, p. 1311). The study above was undertaken in a hospital setting and when computerised physician order entry system (CPOE) coupled with an intervention team being used to prevent the occurrence of ADEs, the research reported a drop to 0.16 per cent for the serious medical errors (Bates et al. 1998, p. 1311). Another study undertaken by Lesar, Lomaestro, and Pohl (1997, p. 1569), that focused on the detection of the errors in the prescription using pharmacist detection. The research found that out of all the prescription errors, 1.3 per cent were associated with medications for psychiatric treatment.

I have chosen the area of practice as older psychiatrist patients may be particularly susceptible or vulnerable to the ADEs associated with the psychotropic medication. Research undertaken by Monette, Gurwitz, and Avorn (1995, p. 203) and Rothschild, Bates, and Leape (2000, p. 2717) noted that the older patients are more vulnerable to psychotropic medication associated medication errors due to the increased susceptibility of the older patients to drug effects, frequency of the use of the psychotropic medications by the elderly, a greater risk of drug to drug interactions due to the polypharmacy use on the older patients as well as the increased difficulty associated with differentiating the ADEs from the patient symptoms and signs changes. A study undertaken over a period of one (1) year on 18 nursing homes noted that 35 % of the ADEs recorded were as a result of psychotropic medications with the research indicating that 63 per cent of the psychotropic medications ADEs could be preventable as compared to just 43 per cent for the other classes of drugs (Gurwitz et al. 2000; p. 87).

Studies have also found that psychotropic medications make up 23 per cent of the medication errors in nursing homes (Beers et al. 1992, p. 684) with older adults in the ambulatory settings receiving higher rates of errors in the psychotropic medications; ranging from 27 per cent and 44 per cent (Aparasu and Fliginger 1997, p. 823; Mort and Aparasu 2000, p. 2825).

Even though the studies above were undertaken in general hospitals that had psychiatric wings, two main studies have indicated the extent of the medication errors in the mental health settings. A study undertaken in the United States over a period of two (2) months indicated significant cases of medication errors. In the study involving 31 inpatients in a psychiatric hospital, there were 9 errors that were self-reported by the health facility; however, following a multidisciplinary and independent review, there were 2,194 errors that were found for the same 31 patients (Grasso et al 2003, p. 677). Out of all the errors noted in the study, 58% of the medication errors were found to have a high risk, while 23% had moderate risk with the other 19% having low risk of harm to the patients. The other study undertaken in a mental health institution include both the outpatient and the inpatient locations focused on the severity, causes, frequency and the costs of ADEs; found that 13.6 per cent of the medication errors that led to psychiatric readmissions (Senst et al. 2001, pp. 1130-1131). Further, the study found that during the psychiatric hospitalisation, the rate of ADEs stand at 4.2 ADEs per 100 hospital admissions.

Impetus behind the transformation

Medication errors, particularly the administration of wrong drugs is a common error type in the health care services (Leape et al 1995, p. 35; Kapborg and Svensson 1999, pp. 950-951). However, to ensure the safety of the patients, it is important to develop a system that can verify that the right drug is delivered to the correct patient; such a system is essential and basic for ensuring the improvement of care quality and the patient safety. Although errors associated with drug identity checking – cases where the health care professionals administer the wrong drug – have been put under the same category with the errors of wrong dose (Leape et al 1995, p. 36), such a categorisation should be reconsidered as part of quality improvement in clinical practice (Ito and Yamazumi 2003, p. 207). Clinical research has indicated that the implications of wrong drug errors are significantly different in terms of corrective action for the errors of wrong dose errors. Wrong drug errors entail the checking errors by the nurses and pharmacists that lead to patients nearly receiving (near misses) or receiving the wrong medication (Leape et al 1995, p. 38). The wrong drug errors are different from the cases of wrong dosage errors where there is a failure by the pharmacists or the nurses to ensure that the proper dosage is administered or dispensed. The wrong drug errors can lead to significant adverse effects when the psychiatrist patient receives a drug that is inappropriate for their condition. When the disorder that the patient has is not treated properly, such a patient is exposed to medication that is not only unnecessary but can also attendant adverse and side effects (Bates 2001, p. 3135).

Wrong drug errors are of critical importance in facilities that offer long-term care such as long-term psychiatric hospitals and nursing homes. The study undertaken by Kapborg and Svensson (1999, p. 955) showed that the wrong drugs administration was one of the most common errors that occurred in nursing homes. In such settings where chronic care is offered, drugs administered to the patients is changed in very rare cases due to the relative stability conditions of such nursing homes; thus lower attention is paid to medication administration. Furthermore, the patient ratios are usually lower in the long-term facilities as compared to the ratios in the acute care. An example of the ratios in Japan indicate a ratio of 1:5 in the psychiatric hospitals as compared to 1:3 in the general acute care in the general hospitals. Even in the NHS, the ratio of staff to patients in the psychiatric care is lower, just as is the case in Japan.

A study undertaken by Smidt and McQueen (1972, p. 398) on the drug adverse effects in a hospital covering all services including all in-patient services found that the adverse events frequently occurred in psychiatric units. The principal treatment in psychiatry and internal medicine is drug therapy; thus more medicines are applied, leading to a greater risk of medication administration errors. The special feature of the existing psychiatric treatments, also compound the medication errors problem. In the long-term care facilities, the psychiatric patients are in some cases trained on the self-administration of the medications to improve compliance and increase the patients’ self-care. Compliance is a complex phenomenon that can strongly contribute to the unpleasant side effects as well as negative attitudes of the psychiatric patients towards the medication (Kampman and Lehtinen 1999, p. 167). Research has indicated that self-administration of drugs can aid in the improvement of illness awareness while also increasing the medication compliance. However, the participation of the patient in the administration of the drugs can also lead to an increase in the wrong drug risk. The first case of the realisation of the high risks associated with wrong drug administration amongst psychiatrist patients came to light in 1972 (Smidt and McQueen (1972, pp. 398-399).

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