Patient Safety Problems

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The aim of this assignment was to select a patient safety problem of interest to me and indicate the extent of the problem and also some approaches that are used to address this patient safety problem. The patient safety problem that will be discussed is medication errors in paediatric patients. This student will discuss increased risks associated with paediatric patients, types of medication errors that are common in paediatric patients in the clinical area, most common types of medication that are prescribed or administered incorrectly and methods used in hospitals to address this issue. Medication errors are perhaps the most common types of medical errors, and in the United States, it estimated that medication errors kill 7000 patients a…show more content…
But, a prospective review of medical records and staff interviews demonstrated that opioids and antibiotics were the two drug classes most commonly associated with drug error (Holdsworth, Ficht & Behta, 2003). In an analysis of five years of data from the United States Pharmacopeia MEDMARX in 2006, morphine and fentanyl have been identified to be the most commonly reported medications associated with harmful paediatric medication errors. C Mc Donnell (MD, MB, BCh, BAO, FFARSCI) carried out a study in 2011 to characterize the specific opioids involved in medication errors, the severity and type of error described. He also set out to review safety reports describing these errors at The Hospital For Sick Children in Toronto, Ontario. This hospital is a 300 bed, university-affiliated children’s hospital serving patients younger than 18 years of age. The most frequently reported opioid in this study was morphine, where 259 reports were filed, second most frequent was fentanyl with 96 reports, followed by hydromorphone with 62 reports, codeine (42 reports) and oxycodone (11 reports). 314 opioid medication errors reached the paediatric patient in total in this review. Forty seven of these patients complained of symptoms, with pain…show more content…
This study was a pre-intervention and post-intervention design that compared medication administration error rates. The intervention consisted of implementing a ‘10 steps to reduce medication errors’ checklist, where plastic pocket cards were provided to nurses and additional copies placed where medications were routinely administered. After this intervention, a decrease in errors was observed with a pre-intervention rate of 17.3% and post intervention rate of 9.2%. Highest priority should be given to patient populations that are considered high risk, such as paediatrics and neonates. Hospitals should focus attention on achieving at least 1 of these 3 goals for medication management: 1) eliminate error, 2) identify errors early before they reach the patient and 3) mitigate the harm if an error happens to occur. Eliminating error can consist of simple steps, and strategies might include removal of drugs from frequent medication use supplies or restricting access to the medication in a way that the drug cannot be mistakenly selected and administered. Healthcare settings should also strive to identify errors before they reach the paediatric patient and can do this by early risk detection measures eg, smart pump technology with alarms for doses programmed outside of an acceptable range for that particular patient (Paparella,

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