Administering the wrong medication to a patient with Parkinson’s disease was one of 28 medication errors recorded by Wairarapa District Health Board in 2016. According to data obtained from an Official Information Act request, the most common medication errors were:
- administering medication against an unsigned order;
- administering the wrong dose;
- administering at the wrong rate;
- and administering the wrong medication.
There were four occurrences of each.
Among the more worrying errors were the wrong medication being administered for a patient with heart failure, and medication administered against an unsigned order for a patient with dementia.
There were also instances of medication not being signed for and possibly not being administered, and medication being delivered through the wrong route. In this case, it was administered through an intravenous (IV) line instead of orally.
Wairarapa DHB chief executive Adri Isbister said the organisation had a focus on medication administration for 2017.
“An annual medication certification programme will roll out to all nurses from April. The first cohort of nurses to complete the programme will be those involved in previous medication errors and then it will roll out to all nurses.”
She said nursing had addressed other contributing factors, and would reduce the amount of interruptions to nurses administering medications by having them wear high visibility vests. The vest would indicate the nurse was on a medication round and was not to be disturbed.
A concentrated effort had gone into attention to detail and back to basics of checking that each individual prescription was prescribed correctly, Mrs Isbister said.
“Nursing is also putting in place mindfulness training to give nursing the tools to be in the moment, and not think of the next 10 tasks they have to do. This will roll out in May or June 2017.”
Intentional rounding was an important part of their structure, she said. “Nurses conduct checks on patients at set times and manage their fundamental care needs. This increases patient satisfaction and decreases the need for patients to use call bells, therefore limiting interruptions.
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