A Near Miss

A Near Miss

[Name of the Writer]

[Name of the Institution]

A Near Miss

The error that happened in the case was the wrong medication. The patient was given five times a high concentration of potassium chloride. The medication error is a crucial issue in nursing. A report indicates that more than 60% of nurses made medication errors. The child was lucky whose mother was from the healthcare field. As a pharmacist, she knew that her kid does not require much quantity of the potassium chloride ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ifS4Z6ak","properties":{"formattedCitation":"(Saskatchewan Health Authority - Saskatoon area, n.d.)","plainCitation":"(Saskatchewan Health Authority - Saskatoon area, n.d.)","noteIndex":0},"citationItems":[{"id":883,"uris":["http://zotero.org/users/local/mlRB1JqV/items/EAVT4VCR"],"uri":["http://zotero.org/users/local/mlRB1JqV/items/EAVT4VCR"],"itemData":{"id":883,"type":"motion_picture","title":"Near Fatal: A Patient Safety Story","source":"YouTube","dimensions":"209 seconds","URL":"https://www.youtube.com/watch?v=pcQUnGiuhzM","title-short":"Near Fatal","author":[{"literal":"Saskatchewan Health Authority - Saskatoon area"}],"accessed":{"date-parts":[["2019",7,11]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Saskatchewan Health Authority - Saskatoon area, n.d.). The cooperation and trust of the physician on the mother helped in sorting out the error. However, it is important for nurses to identify and solve these kinds of medication errors.

The first factor that could lead to medication error was the lack of pharmacological knowledge. It could be identified through the kidney condition of the patient which suggests that the normal quantity of potassium chloride was enough. Therefore, the nurse could prevent the error by preventing the wrong infusion rate and dosage. The second error observed was the communication gap. The communication between the nurses, nurse with physicians, and nurses with parents is really important for safe practice. It helps when the thing goes out of hand. Therefore, the nurse could reduce the communication gap to avoid any complication in the case. The last thing where the nurse could prevent the error was the handwritten report. The report indicates that numbers of time medication error happen due to the abbreviation used by the nurses. In the video, it can be observed that nurse cut the words various time. Hence, technology advancement is important. The report should not be handwritten instead it should be typed through the computer for better understanding. The bottom line is that the nurse could prevent the error through pharmacological knowledge, better communication, and digital reporting system ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qupmdwcs","properties":{"formattedCitation":"(Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013)","plainCitation":"(Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013)","noteIndex":0},"citationItems":[{"id":881,"uris":["http://zotero.org/users/local/mlRB1JqV/items/R5NW7MVN"],"uri":["http://zotero.org/users/local/mlRB1JqV/items/R5NW7MVN"],"itemData":{"id":881,"type":"article-journal","title":"Types and causes of medication errors from nurse's viewpoint","container-title":"Iranian Journal of Nursing and Midwifery Research","page":"228-231","volume":"18","issue":"3","source":"PubMed Central","abstract":"Background:\nThe main professional goal of nurses is to provide and improve human health. Medication errors are among the most common health threatening mistakes that affect patient care. Such mistakes are considered as a global problem which increases mortality rates, length of hospital stay, and related costs. This study was conducted to evaluate the types and causes of nursing medication errors.\n\nMaterials and Methods:\nThis cross-sectional study was conducted in 2009. A total number of 237 nurses were randomly selected from nurses working in Imam Khomeini Hospital (Tehran, Iran). They filled out a questionnaire including 10 items on demographic characteristics and 7 items about medication errors. Data were analyzed using descriptive and inferential statistics in SPSS for Windows 16.0.\n\nResults:\nMedication errors had been made by 64.55% of the nurses. In addition, 31.37% of the participants reported medication errors on the verge of occurrence. The most common types of reported errors were wrong dosage and infusion rate. The most common causes were using abbreviations instead of full names of drugs and similar names of drugs. Therefore, the most important cause of medication errors was lack of pharmacological knowledge. There were no statistically significant relationships between medication errors and years of working experience, age, and working shifts. However, a significant relationship was found between errors in intravenous injections and gender. Likewise, errors in oral administration were significantly related with number of patients.\n\nConclusion:\nMedication errors are a major problem in nursing. Since most cases of medication errors are not reported by nurses, nursing managers must demonstrate positive responses to nurses who report medication errors in order to improve patient safety.","ISSN":"1735-9066","note":"PMID: 23983760\nPMCID: PMC3748543","journalAbbreviation":"Iran J Nurs Midwifery Res","author":[{"family":"Cheragi","given":"Mohammad Ali"},{"family":"Manoocheri","given":"Human"},{"family":"Mohammadnejad","given":"Esmaeil"},{"family":"Ehsani","given":"Syyedeh R."}],"issued":{"date-parts":[["2013"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013).

References

ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research, 18(3), 228–231.

Saskatchewan Health Authority - Saskatoon area. (n.d.). Near Fatal: A Patient Safety Story. Retrieved from https://www.youtube.com/watch?v=pcQUnGiuhzM