Sunday, May 6, 2018
Hospital Error
Have you ever had to investigate any cases of error during your time working in a supervisory role in a hospital? Would you be able to discuss what happened, while preserving the anonymity of all involved? Were any steps taken to make it less likely that such mistakes would happen in the future?
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I have experienced some abbreviation that is not international use such as CQ which intended to stand for Chloroquine. However when looked carefully at patient profile, there was only one choice for it, it did take time. In practice consulting with physician in every cases with the limited of time is impossible, the pharmacists prefers figure it out by themselves. To solve this kind of problem can be encouraging physician to use computer program to prescribe medicine and write a full medicine name.
ReplyDeleteI think so Pong.
DeleteGreat, you can be encouraging a doctor.
DeleteAn interesting account! Have you ever, though, had to contact a doctor who wrote a prescription to check what an abbreviation meant? :-)
DeleteChanging the behavior of a doctor is very difficult isn't it?
DeleteIn my opinion looked carefully at patient profile
Deleteis the connect of PH&PI.
The use of acronyms should be universal, consistent with the multidisciplinary understanding.
DeletePrescribing on computer is becoming a trend in many hospitals now. I think the new standard of prescribing will be used in the near future though.
DeleteDid your case occur in In- patient or Out-patient ?
DeleteThe doctor had prescripted Salbutamol (Ventolin solution)-bronchodialator drug, for a child who had an asthma attack at the emergency room in primary health care unit. The child was 6 years old. The doctor writing was illegible and resulted in the child being given 1:3 ventolin. I was not sure about this. So, I asked the doctor for the right dose. In the future, we should use read-back procedure to prevent medication errors as a nurse.
ReplyDeleteI think so P'Aon next time be careful and read-back prescripted.
DeleteThe nurse should help to determine the dose or medication that will be given to the patient to prevent any furture complication.
DeleteGood way for nurs double check medicine before take care your patients. #goodnurse
DeleteIn the article about the hospital-wide study on prescription writing, a read-back procedure was recommended if a prescription was given orally. Do you think this procedure is useful for written prescriptions as well?
DeleteI think so,many nurses have to be the meticulous and thorough person.
Deletedouble check good and safe for everyone.
DeleteThe student clearence for detail of 7 R. RIght drug trade name and genericname.
DeleteRead-back procedure will be so difficult for any physicians if information and prescription were written illegibly.
DeleteIn the last month, I have experienced use medicin for patient in the hospital. I teach student nurse in Orthopedic surgery department for injection. In addition, prepare medicin for all patient around 30 patients. My student has confused name of medicin becouse the name of the medicin is similar such as Cefazolin and Certriaxone. Fortunately, I checked again before giving to the patient. I warned students to use 7R, Right drugs, Right dose, Right time, Right patient, Right record, Right medthod, Right to refuse. If student nurse, nurse, doctor or healthcare does not follow the principles taught, it can cause problems for the patient.
ReplyDeleteGood teacher.
DeleteI totally agree with the idea of using 7R in the administration method. It would help to prevent error.
DeleteI agree with you because the 7R technique is an important method before we will take medications for patients as a nurse.
DeleteGood work.prepare medicin for all patient around 30 patients to use 7R is very importance
DeleteI'm agree with you. I think that the medication administration has to use 7 right principle for rechecking of the medication procedure in every step.
DeleteInteresting post. What exactly does 'right to refuse' mean? Is this referring to the patient's right to refuse to take a medication?
DeleteGood 7R is very important especialy when we taught student.
DeleteI think so.
DeleteBy March 2018, I taught students in hospitals. When it is time for the patient to be injected, it will be checked for the type, size, and name of the patient on the medication record. Patient records will be checked with every patient's card to see the patient's medication accuracy. However, when the drug record was checked against the chart, the patient's drug records were not matched. The name of the drug was similar. ceftriazone with cefazidime There is a need to talk to the staff in the ward about the need to record the drug again to ensure the safety of the patient.
ReplyDeleteThe name of the medicine is very similar, reading the medicine out loud can help.
DeleteIn your ward have a many and similar medicine.You are good teacher and work hard.
DeleteI think so need to talk to the staff in the ward about the need to record the drug again to ensure the safety of the patient because the staff has know whole patient and she look after 24 hrs.
DeleteIn my opinion,the knowledge of drug name and it's action is very important for the multidisciplinary team because some drug has very similar name but it 's action is not similar.
DeleteI agree with you because nurse makes hard work and can less to relax. So,double check is good way for nurses working.
DeleteA systematic approach is needed to prevent medications being confused, isn't it. If you have a system for checks in place, it can protect health professionals from making mistakes when they are tired and stressed and when they are responding to emergencies.
Delete2 year ago I taught student nurse in labor room. My student prepare medicine and check before injection.The Obstetrician was wrong order she write Dexamethasone 6 mg IV but this medicine use 6 mg IM. I told staff nurse and she asked the Obstetrician Oh, she so sorry and edit her Order.
ReplyDeleteOh that's dangerous, I grad that you can checked it before it was administered to the patient.
DeletePrior to administering the medication to the patient. Always keep a record of your medication and prescriptions before administering the medication.
DeleteIn the next time we must to control this student and check her befor to treatment.
Deleteyou're a genious nurse instructor.
DeleteYou have a good teacher, good luck for patients and your student nurse.
DeleteGreat that you were able to pick up this mistake! By the way, I understand IV, but what is IM?
DeleteYou are the good model when you met medical error.Good teacher.
DeleteActually, I have more experienced about hospital error, for example, blood transfusion error, patient identification error and medication error but medication error was the most common hospital error. I realized that medication error can occure in every process , for example , In precription and transcribing error, the doctor prescriped Enarapril (Antihypertensive drug) 1 tablet 2 times a day for a man who had hight blood pressure but the doctor had illigible handwritting so that the nurse transcribe his order wrongly and gave enalapril 1 tablet 3 times a day and then the pateint had low blood pressure .I did recheck his vital signs and report a dortor to check his symptom and recheck the antihypertensive drug that the patient had with the nurse so they know that he had drug overdose . To solve this kind of problem , the dortor stoped this drug and monitored the patient ' s blood pressure until it stable. In my opinion the multidisciplinary team have to work together , recheck and confirm each other and be careful about handwriting.
ReplyDeleteCheck the drug orders of the doctor if you not confident, you should check the order with the doctor again to prevent mistakes that will occur.
Deletethat good idea multidisciplinary team have to work together.
DeleteI do agree that health care team have to work together to provide the best and safe care for patients.
Deletefirstly.We are checking the doctor prescriped and recheck from chart very important
DeleteThis is serious situation that resulted from medical errors.Nobody doesn’t want this situation occurring to our family.That’s why we will check the prescription before we will take medication for patients that’s one of 7R methods as a nurse can do under our authorities.
DeleteGood luck for your patients ❤️
DeleteNumbers can easily be confused if not written carefully. Thanks for sharing your experience!
DeleteIn the past 10 years ago. I had a significant experince for me. I went to a hospiat with my student nurse at HEENT for train practice about nursing. What a wrong something with a patient??
ReplyDeleteActually,In my students case study who has got a wrong Augmentin (Its a drug name). a child who was bee a my student case. He is a acute tonsillitis who stay admit in a general hospital about 4-5 days for treat antibiotic. while he get a wrong drug`. so he still along time stay at hospital because he have to investigate laboratory such as liver function test
Deletewhat is the medicine that your student gave?
DeleteIt is bad. Prior to administering the medication to the patient. Always keep a record of your medication and prescriptions before administering the medication
Deletewe have check seriously for history medicine.
DeleteSo Dangerous. you carefully recheck your student nurse with 7 right principle.
DeleteOh, that a good way for use 7R.
DeleteIt is dangerous 7R is very important.
DeleteYes, I'm also interested to know what happened here. Was Augmentin the drug that was given by mistake, and if so what should the patient have been given?
DeleteMedication administration error was the most common medication error. Everyone who has to give drug to the pateint should have more knowledge and pay attention to every imformation.
DeleteMany years ago.I had a significant experince for student error patient identification error and medication error .There are lost of the 6 R’s(Right Drug, Right Dose, Right Route, Right Time, Right Patient, Right Documentation.Right Patient is the importancest because we are should Identification. drug to the wrong person. For instance are they allergic to it I do ask you have any allergies for any medicine? with regularity that drug the right patient. it is necessary the first.
ReplyDeleteIt's a same situation. How do you coping that situation?
DeleteThat is good. I think so.
DeleteDrug allergy information normally indicated in patient profile, Did profile written that information?
Deletegreat, I think so.
DeleteThe best nurse instructor 👩🏫
DeleteI have ever had some experience like you .The doctor prescibed "Tramal" but the pateint allergic to tramal (Drug allergy information indicated in patient profile already but the doctor did not see it). Before I gave drug for the pateint,I had asked drug allery imformation and knowed that the pateint had allergy to Tramal thus I did not give Tramal for the patient.Sometime in rush hour the dogtor do not pay attention to important imformation thus The nurses who have to give drug for the pateints shold confirm every improtant imformation.
DeleteGreat I think so.
DeleteGood post. Interestingly, this is one of the questions I often remember doctors and dentists asking me: "Are you allergic to any medications?"
DeleteI had experince with the medical error when I taught in the delivery room. My student recived assignment to attening pataint in bed 5 and the doctor order drug for induction labor stage.I told her to reading the order and prepare drug for this patient when prepration finsihed she asked me to confirm so I met she made somthing wrong and very dangerous for the pateint. She prepare drug with very hight dose so I told her stop and taught her about this mistake.
ReplyDeleteThis comment has been removed by the author.
DeleteIn the next time assignment the student recheck protocol 6R or 7R inspecific Right dose calculate number for dose.
DeletePatients should be monitored for drug administration before administration.
DeleteEvery times when you prepare some medicine for patients, just ask “What is your name?”
DeleteMaking this mistake during her training will probably have taught this student the gravity of making a mistake with a prescription. She will no doubt be a more vigilant nurse because of this experience.
DeleteI experienced mistake which was made by a patient's illegible handwriting three years ago. In a dental practice, the new patient would be told to write his information to inform dentists whether he had any health issues that would concern dental procedure. He wrote on his chart in Thai that he was allergic to "Penicillin" in illegible handwriting. I was the dentist that he was seeing that day. Before I injected local anesthesia to his tooth, I had read his chart. Unfortunately, I was mistaken about his drug allergy history so I gave him the exactly same antibiotic pills that he was allergic to. I have learned from this mistake that the patients shouldn't be told to write their own information in charts. Moreover, medical or dental providers should pay attention on every details in charts in order to avoid mistake.
ReplyDeleteI think so.Anesthesia is very dangerous medicine someone was allergic and anaphylactic shock we must awearness right dose and right route.
DeleteThe wrong lesson will teach us to be more careful.
DeleteYes, totally agree patients should not write their own information in the card to prevent error and misunderstanding.
DeleteThis is good to make you remind and avoid in another patient.
DeleteAbsolutely, important for prevention medicine error.
DeleteThanks for sharing. This experience has no doubt confirmed for you the importance of legibility in medicine.
DeleteWhen I was a hospital pharmacist, I experienced the medication error issues which related to doctors' prescriptions. On that day, the hospital information systems did not working so the doctors had to prescribed manually. Unfortunately, the prescription that I read had been written with the illegible handwriting. The mdication that the doctor wanted to use with his patient was Lasix, trade name of furosemide which uses in hypertension and heart failure, but I thought I might be Losec which is used to treat stomachache. This circumstance is called Look Alike Sound Alike ( LASA) which is the main medication error in a pharmacy department.
ReplyDeleteThe ways to prevent such problem are encourage doctors to prescribe with readable handwriting and use the generic name instead of trade name. Secondly, pharmacists should be aware when reading prescriptions, in case of unreadable prescribed medication occuring should ask the prescriber to clearify it immediately.
It is a good idea. The wrong lesson will teach us to be more careful
DeleteTeamwork for health care there are prefesional 7 Rs so medication errors are preventable event that may cause lead to inappropriate medication use patient harm while the medication is in the control of the health care
DeleteYes, trade name should be avoid to use in the prescription. It also help when hospital does not have that trade name can automatically change to other trade name which is the same medicine
DeleteInteresting post. Good to know of the procedures in place to help minimise cases of 'look alike, sound alike.'
Delete