Clinical Reasoning Can Prevent Medication Errors

Medication errors are the most common errors in health care. In fact, the average hospital patient can be subjected to at least one medication error per hospital day, and these errors may account for up to 7,000 hospital deaths every year. Fortunately, by relying on clinical reasoning and appropriate actions to intercept these errors before they reach patients, nurses can prevent many medication errors before they occur.

According to a recent study in Qualitative Health Research, nurses intercept 50% to 86% of potential medication errors. Through in-depth interviews, researchers found that medical-surgical nurses use more than the traditional “five rights” of medication administration: right patient, medication, route, dose, and time. They also rely on two clinical reasoning themes—maintaining medication safety and managing the environment—to protect patients from medication errors.

Clinical Reasoning and Medication Safety

Nurses know that although electronic medical records are valuable tools, relying too heavily on them can pose risks. Keeping clinical reasoning skills sharp helps keep patients safe. To support clinical reasoning, nurses follow specific safety practices that include:

• Patient education—Nurses review each medication and dose with the patient before administration. If anything seems odd, the nurse stops, checks the original order, and may go back to the notes to confirm the medication or discuss it with the physician or pharmacist. Nurses also collect information about their patients to help them predict which medications they need and recognize when something isn’t right.

• Considering everything—Nurses consider the patient’s age, weight, laboratory test results, treatments, allergies, and other factors related to medication administration. If a drug does not seem right for a patient based on this information, they make evidence-based decisions, consulting drug books, web-based drug data, and pharmacy personnel.

• Patient advocacy—Nurses advocate for their patients. When medication delivery isn’t on-time or when drugs simply aren’t delivered, they call the pharmacy, mark the drug “stat,” retrieve the drug themselves, or sometimes place it in a “safe” area off the medication cart to ensure that it’s available for their patient.

• Care coordination—Nurses speak directly physicians, asking questions and working as a team. When nurses must challenge physicians, they provide data directly from patients and their records.

• Medication reconciliation—Night nurses routinely reconcile medication administration records (MARs) or electronic MARs (eMARs) with original physician orders every 24 hours. However, if these nurses overlook an order, the error can be perpetuated. So the patient’s nurse regularly reconciles MARs or eMARs with the physician’s orders as an extra safety precaution.

• Verification—To further enhance patient safety, some nurses develop relationships with expert-nurse peers who can help them verify medications or check questionable orders with peers. In one example, a team of certified chemotherapy nurses calculated and recalculated drug doses independently and then together as a safety precaution. Other nurses worked with their managers to implement additional safety practices.

Managing the Environment

Because distractions and interruptions can contribute to medication errors, the environment also must be considered. But nurses alone cannot resolve environment-related medication safety issues. They must find solutions that require hospital policy changes. In doing so, they focus on four basic areas:

• Interruptions—Any interruption can divert a nurse’s attention from medication administration. Some techniques that nurses use to avoid unnecessary interruptions include asking medical secretaries to hold calls (except for emergencies), finding a quiet spot to prepare drugs, or wearing a red vest marked “I am passing meds, please do not interrupt.”

• Physician orders—Although computerized physician order entry systems have minimized problems from illegible physician handwriting, only a few hospitals have these systems. Hospital policies require the avoidance of easily misinterpreted information, such as Latin abbreviations and hanging zeroes, but not all physicians follow these guidelines. When a physician order is in doubt, nurses call physicians to confirm the order.

• Near misses—When nurses head-off a physician or pharmacy error, they may just call to let the person know (especially if no patient harm would occur) rather than file a report. However, some hospitals encourage nurses to report near misses because doing so helps improve patient safety.

• Interdisciplinary communication—With the hospital administration’s support, nurses, physicians, and pharmacists can collaborate to prevent system errors. By working together, members of each discipline can find the best solutions to medication errors.

To learn more about proper medication administration and preventing errors, look into Mosby’s online course, AACN: Critical Care Pharmacology. Call 1-866-416-6697 or email [email protected] for more information.

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