|
Miscommunication
of drug orders
This article was
published in The West End
Times October 29, 2011.
Medication
errors are said to affect at least 1.5 million Canadians per year.
According to
the Canadian Institute for Health Information, one in 10 patients
receives the
wrong medication or the wrong dose while in hospital. The Canadian Institute for
Health Information's
fifth annual report (Health Care in Canada 2004) used the institute's
studies
and Statistics Canada data to examine patient safety. For the first
time, it
compared how common some errors are. Nearly a quarter of Canadian
adults say
they or a family member have experienced a preventable medical error.
Drug
errors and infections top the list.
It is estimated
that the number of lives lost to mistakes that could have been avoided
with
medication error prevention techniques alone represents approximately
7,000
deaths annually, and medication errors occur in just about one out of
every
five doses given in hospitals. These are voluntary reports and we know
that
many errors may go unreported, so the number of medication errors that
actually
occur is thought to be much higher.
Because the practice of medicine is so complex, there
are
many opportunities for mistakes to occur at any step between diagnosis,
transcription, prescription and administration of the medicine. Some of
the
most common causes of medication errors include:
- disorganized work flow
- fatigued staff
- frequent interruptions and distractions
- emphasis on volume over service quality
- stress
- ineffective communication with patients
- A pattern of inadequate staffing.
- Miscommunication of drug orders; which can involve messy
handwriting, incorrect abbreviations, confusion between drugs with
similar names, misuse of zeroes and decimal points, confusion of metric
and other dosing units;
- Knowledge deficits due to improper training or education;
- Unavailable drug information (such as lack of up-to-date
warnings)
- Lack of appropriate labeling as a drug is prepared and
repackaged into smaller units. And the list goes on and on….
Although many would like to put the blame on a
particular
individual for medication errors, I prefer to blame the system and the
fact
that we do not find a “Better Way.”
How about counseling patients about their medications and showing the
pills to
the patient to be sure they are what they expect? The problem is that
there is
very little teaching going on. Nurses spend so much time dispensing
medications
while that time could be better spent educating the patients to self
medicate
safely. Too often patients are sent home with no knowledge about their
medications only to be told that they are non-compliant and to blame
for their
poor health. Just take your pills!!!
Years ago when I worked in hospitals I proposed that
we teach
patients about their medications and the reason for taking them. Once
it is
determined that they understand what they are taking, for what reason
and the
possible side effects, their medication could be locked in their
bedside tables
for self administration. As soon as we place patients in hospital beds
we think
they are no longer capable of looking after themselves. What a waste of
nurses’
time and what a loss of learning opportunities for patients.
After 15 years working in home care I am shocked that
little
has changed. I am even more convinced that hospitals should be for a
diagnosis
and immediate treatment needs and there should be a real push for early
discharges to home. With support, monitoring and teaching about their
care
needs including medication follow-up, people can do very well and stay
out of
hospitals. And yes…….we now have the technology to
monitor and teach remotely
at a fraction of the cost to the health care system. Let’s put
people in charge
and give them the necessary tools to do so.
I enjoy getting calls and feedback. Thanks for your
calls and messages. If you leave your number, I will get back to you. I
am looking for five people who would like to try our free monitoring
from the comfort of their home. For more information contact me at
Health Access Home and Nursing Care
514-695-3131, donna@ashcanada.com. www.ashcanada.com
|
