Drug errors are undoubtedly a serious issue and strategies to prevent them are important in order to maintain patient safety. The use of strategies like the red tabard system have very much come under criticism of late, but do systems like this actually prevent errors from occurring? And what happens when an error does occur? How do we report it and what constitutes a serious drug error?
There is no doubt that any drug error is a serious and stressful event in any nurses career, do reporting systems ensure that the nurse is supported and learns from these events? With seven out of ten fitness to practice cases brought to the NMC involving drug errors (Lomas 2010) does this sometimes lengthy process ensure that patients are safe and nurses are treated fairly?
Thanks goes to @susiqa for this discussion suggestion
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If you would like to do some background reading prior to the discussion then please click on the links below – please feel free to add to this if you have anything interesting to share.
NMC Standards for medicines management
Preventing and reporting drug administration errors Chloe Copping 2005 – Nursing Times
Fearful staff quiet over drug errors Clare Lomas 2010 – Nursing Times
How do we reduce drug errors Ingrid Torjeson 2008 – Nursing Times
Reducing medication administration errors in nursing practice Jones 2009 – Nursing Standard
Building a safer NHS for patients Improving medication safety – Department of Health
Red tabards keep patients safe and should not be undermined Steve Ham 2011 Nursing Times
Summary by Teresa Chinn RN
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Post Chat Summary
The discussion on the preventing and reporting of drug errors began by exploring if nurses often saw drug errors in their workplace. It was cited that common errors included omissions and forgetting to sign drug charts. Strategies to prevent drug errors were also discussed ranging from bar coding found in some care homes, to minimising distractions and interruptions and red tabards.
There were worries over healthcare environments who reported zero drug errors and whether this was due to them just not being reported. Having an culture that was not about blame was brought up as being important. Being given the chance to learn from errors was seen as being good. In general it seemed that everyone felt that nurses were quite well supported in their workplace when genuine errors were made.
Using pharmacists to administer medication was discussed and although it was agreed that they had very specific specialist knowledge of medicines it was thought that they would generally be open to the same human error and this would not necessarily prevent drug errors.
Better training and more training in polypharmacy was seen as being necessary in preventing errors in addition to regular updates.
Self administration was mentioned and again this had been seen to work in some care home environments but safe storage of individual patient medications on a busy ward was seen as a barrier. And in some cases, eg insulin self administration the nurse would still need to observe and sign. Kettering Hospitals self administration was identified as interesting and linked here http://t.co/E2GXxjrX
It was agreed that administration was just one step in a process of and that drug errors could occur at any time, not just during administration. Another article was tweeted about the five rights and can be found here http://t.co/unI6OBL1
Summary by Teresa Chinn RN
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Chat Transcript (reverse chronological order):
NurChat Thanks again to @susqa for this discussion - we are always open to suggestions so if you have a burning issue please share #NurChat 9:01
NurChat RT @PamNelmesFoH: @Mrs_Tufty Question, challenge, read, observe, talk to patients. Administration is just one step in a complex process #nurchat 8:54
MrsGracePoole @anniecoops @pamnelmesfoh #nurchat yes that's my point. Long term benefits to self admin. 8:48
AgencyNurse i have seen self administration alot in care homes though and it generally works well #nurchat 8:48
AgencyNurse @PamNelmesFoH @anniecoops would there be safe storage issues? how would that work ? #nurchat 8:44
anniecoops @nurchat #nurchat what about patient self administration as part of soultion: http://t.co/5JtY9xsu 8:39
AgencyNurse RT @anniecoops:#nurchat re productive series yes there is a great set on reducing medication errors from #nhsinstitute worth a look #nurchat 8:35
dmarsden49 @anniecoops #NurChat am I right in thinking that medication errors is part of the productive series reporting? 8:30
@anniecoops #NurChat isn't that the point, that unconscious competence doesn't just appear it has to be nurtured, and that involves... 8:28
anniecoops @nurchat #nurchat I think this is the current the most up to date guidance to reduce errors: http://t.co/LZK3uQci 8:23
anniecoops @NurChat #nurchat : yep here is more but not had chance to read them! http://t.co/2ZbespCo 8:17
anniecoops @NurChat #nurchat there are some publications aropund about it: http://t.co/b7PWLUs8 8:15
nursiedeb @emrsa15 that is an excellent point. Denial is not just a river in Egypt. would like to see a change from blame culture tho #nurchat 8:15
nursiedeb @emrsa15 that is an excellent point. Denial is not just a river in Egypt. would like to see a change from blame culture tho #nurchat 8:15
emrsa15 @PamNelmesFoH absolutely. The drug round is too full of interruptions and distractions #nurchat 8:12
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