3.2 Drug Errors and Prevention

Autonomy

Autonomy in medicine essentially means having the right to make one’s own health care decisions, being independent, and having control over oneself. In the past, Western medicine operated under a paternalistic style of authority with a “doctor always knows best” philosophy. The physician guided the client’s care, sometimes with little input from the client or family. In 1979, Beauchamp and Childress (2013) introduced the idea of autonomy as it related to biomedical ethics and identified that a client should be able to make uncoerced and informed decisions about their health.

A crucial piece of autonomy is having sufficient information to make a sound choice. Informed consent can assist the client in making appropriate choices for their body and deciding whether to pursue or decline specific medical treatments recommended by their provider. According to Varkey (2021, p. 19), “the requirements of an informed consent for a medical or surgical procedure, or for research, are that the client or subject (i) must be competent to understand and decide, (ii) receives a full disclosure, (iii) comprehends the disclosure, (iv) acts voluntarily, and (v) consents to the proposed action.” The consent itself simply means that the client has the right to be told about a treatment or research in language that is easily understood and specifically told why it needs to be done, the risks or benefits, and alternative treatments. The client then has the right to refuse or allow the proposed treatment. The provider should not attempt to persuade or coerce the client to accept the treatment. The nurse is also obligated to respect a client’s opportunity to choose or decline a treatment. Not only does a client have the right to select the appropriate treatment, but the nurse must respect that choice once the decision is made (Walker, 2022).

Within the setting of medication administration, autonomy means clients have the right to refuse a drug that has been ordered for them. Although the nurse may perceive that the drug is good and will be beneficial to the client, the client may have a different viewpoint. That must be respected once the client is informed about the benefits and risks of a drug. This empowers the client to participate in their care, with the aim of better adherence to the overall plan of care.

Today, the shift is toward client-centered care. This empowers the client to be self-directed and still allows for a relationship with health care providers that encourages dialogue and partnership. This is particularly important for those with chronic diseases. Being part of a partnership and having a sense of empowerment increases safety, improves outcomes, and decreases costs (Lian et al., 2018). Other benefits are increased self-confidence on the part of the client and improved adherence to the medical regimen. An example of a model of client-centered care can be seen in Figure 3.2.

An essential component of choice or exercising autonomy is competence on the client’s part. The client must have the ability to act autonomously. An individual who is not competent (someone who has been determined to be incompetent) may not be able to make a decision in their best interests because they cannot understand their own situation or the consequence of their decision. In this case, having a surrogate to make decisions would be in the client’s best interests.

Figure 3.2 This is an example of a client-centered model of interprofessional care. All professions interact with each other and the client, but the client is at the center of the plan of care. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Beneficence

Beneficence is a principle that requires nurses to “do good” to actively promote their clients’ health and well-being. They also must prevent and remove harmful situations that might affect their client. Beneficence implies an ethical obligation to abstain from injuring the client in any way, whether physically, psychologically, or morally. It involves mindfulness of the client’s entire situation and needs.

Nonmaleficence

The principle of beneficence extends to nonmaleficence, which requires that nurses do no harm to the client and do all they can to safeguard a client from harm. Obviously, intentional harm goes against the principles of beneficence and nonmaleficence; however, many acts performed by the nurse have the potential to cause harm unintentionally. For example, not all clients experience adverse effects of medications, but the potential is always there. A nurse could administer a medication hoping to make the client feel better, but an adverse effect may do the opposite and cause harm. An example of this might be a nurse who administers an opioid for a client’s pain and then reevaluates the client 30 minutes later and observes that the client has developed respiratory depression.

When administering drugs to clients, the nurse must recognize that although the drugs are intended for good, all medications carry some risk to the client. Before any drug is ordered by the provider, the benefit of the drug versus the risk of the drug is considered. Before any drug is administered to a client, the benefit of the drug versus the risk of the drug is again weighed. The client should be fully informed of the benefits as well as the risks of any medication.

Justice

Justice is the principle relating to clients’ fair and equitable treatment (Varkey, 2021). Each individual should be treated appropriately and equally. They should be allowed access to the same treatment and health care resources without prejudice or social discrimination. Even time can be a limited resource as it relates to visits with a provider because for more complex cases, more time might be necessary; however, that may shorten the time allotted to another client. The distribution of resources can be difficult to balance, especially when resources are limited (as in the case of organ transplantation) or in the case of uninsured clients. Justice is denied if an expensive medication would cure a client of their disease but a less expensive treatment was recommended because it benefits the provider in some way. Another example would be in the case of expensive drugs going only to those who have insurance or financial resources.

Veracity (Truth-Telling)

Veracity is important to building trust in the provider–client relationship (Varkey, 2021). The client should be able to ask the provider about their diagnosis, prognosis, and potential treatment. Refusing to divulge the truth to clients with a terminal diagnosis means that they are unable to finish important life tasks, say goodbye to loved ones, put financial affairs in order, or put their spiritual life in order (Fallowfield et al., 2002). When providers are not honest with clients, it may cause fear, confusion, or anxiety, especially in cases where the provider discloses the truth to the family but not the client.

Adverse Drug Reactions

The World Health Organization (n.d., p. 1) defines an adverse drug reaction (ADR) as “harmful, unintended reactions to medicines that occur at doses normally used for treatment.” Coleman and Pontefract (2016, p. 481) define an ADR as “unintended, harmful events attributed to the use of medicines.” Side effects, a type of ADR, are considered to be secondary drug effects produced at therapeutic doses. An example of this might be sedation related to the use of an antihistamine or diarrhea related to the use of a stool softener. An allergic reaction is an immune response due to sensitivity to a specific drug. A mild allergic reaction can cause itching and rash, but anaphylaxis is a severe, life-threatening reaction causing dangerous bronchospasm and hypotension. These drug reactions affect the safety of the client but are not due to a medication error on the part of a health care provider.

Medication Errors

According to the National Coordinating Council for Medication Error Reporting and Prevention (2023), a medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” In 1999, a landmark report by the Institute of Medicine, To Err Is Human, increased awareness of medical errors in the United States. This report stated that as many as 98,000 people die in hospitals yearly due to medical errors. The following year this was validated with the clarification that medication errors in health care facilities are the most common type of these errors. This article describes 25 common medication errors in nursing and prevention recommendations.

The FDA receives more than 100,000 reports of drug errors each year, but more than 7 million clients in the United States are impacted by medication errors annually (da Silva & Krishnamurthy, 2016). Adverse drug events account for almost 700,000 emergency department visits each year (AHRQ, 2019b). The cost of caring for individuals whom a drug error has harmed exceeds $40 billion annually (Tariq et al, 2023). The financial and human costs of these errors are staggering.

An adverse drug event (ADE) is client harm resulting from exposure to a drug. This is injury from a medication, a missed medication, or an inappropriately dosed medication. It may or may not result from an error or poor-quality care. Medication errors that do not cause harm to a client (perhaps due to luck or the drug not reaching the client) are considered to be potential ADEs; in contrast, if harm to the client occurs, it is considered a preventable ADE. A drug can be prescribed, dispensed, and administered correctly, but the client may still experience an ADE. This is considered an adverse drug reaction (discussed in the previous section). This is an expected adverse outcome due to the drug’s pharmacological action and is not always preventable (Tariq et al., 2023). Medication errors, however, are preventable.

If a physician orders an incorrect dose of a medication but the pharmacist catches the mistake before dispensing it, it is considered a medication error. If the physician orders the correct medication and dose but the pharmacist dispenses the wrong dose, it is a medication error. Errors may be related to any of the following (and this may not be an exhaustive list) (Tariq et al., 2023):

• Deteriorated drug
  • Product expired
  • Product stored incorrectly
• Error in prescribing
• Extra dose
• Insufficient monitoring
• Known allergen
• Known contraindication
• Omission of drug
• Wrong client
• Wrong dose
• Wrong diluent
• Wrong drug
• Wrong infusion rate
• Wrong preparation
• Wrong route
• Wrong strength or concentration
• Wrong time
• Wrong technique
  • Crushing an extended-release tablet
  • Administering a subcutaneous medication using an intramuscular technique

According to the Agency for Healthcare Research and Quality (MacDowell et al., 2021), medication administration is a very complex process characterized by the involvement of many health care team members, not just the nurse. Many institutions are working on ways to improve technology and workflow to make the process safer for the client. The manufacturer, packager, provider, pharmacist, technician, and nurse are all part of the process—and each is in a position to make an error. There are many different ways for an error to occur, but in the clinical setting, the nurse is the final person in the chain able to prevent an error from occurring.

Some errors harm the client directly, but others may harm the client indirectly. Administering the wrong drug or doubling the dose of a medication may harm the client directly, whereas giving too little medication may cause a client to be undertreated and not take care of the disease, thereby causing harm indirectly. The most common types of lethal medication errors include giving an overdose of a medication, giving the wrong medication, and giving the drug by the incorrect route. Failure to monitor kidney or liver function can also impact the client’s safety.

Prevention of Medication Errors

To prevent some of the previously described communication errors, many institutions have order read-back policies for verbal or telephone orders. The nurse or pharmacist first transcribes the order and then reads it back to the physician. Many institutions have policies recommending that if a written order is illegible, the pharmacist or nurse must call the provider to clarify rather than guess what the provider intended. Computerized order entry has decreased the incidence of illegible orders; however, there is still the chance that an incorrect dosage or route may be entered. Errors from the confusion of medication names occur because many drugs have names that sound alike or look alike, such as Celebrex, Cerebyx, and Celexa or dopamine and dobutamine. (See the List of Confused Drug Names from the Institute for Safe Medication Practices (ISMP) for more information.)

In the past, an individual was often blamed when medication errors occurred. Many errors were thought to be the result of procedural violations, negligence, or carelessness. As a result, individuals may have received disciplinary action (even firing), loss of license, or threat of a lawsuit. Institutions are slowly shifting their culture from “naming, blaming, and shaming” to “how can we improve the system to prevent errors.” When shaming and blaming occur, it reduces the willingness of some individuals to come forward and acknowledge their mistakes. This may harm the client because the error is unreported, but it may also lead to another person making the same error if the fault is in the system. There has been a gradual move to a “just culture,” which refers to a system of shared accountability. The organization may not have provided adequate training or had inadequate policies and procedures in place, or poorly designed units. In a just culture, the organization is accountable for the system or process it has designed as well as behaviors. Ideally, organizations will move away from policies that require punishment for errors and focus on reinforcing principles that decrease “at-risk” or reckless behaviors.

James Reason (2000) developed the Swiss cheese model (see Figure 3.3), which drew attention to the occurrence of client harm as a result of failures in the health care system itself. Each barrier to client harm has a weakness (or hole); thus, Reason likened this to Swiss cheese. When all of the holes are aligned, the hazard (in this case, a medication error) reaches the client, and harm will occur. Figure 3.3 depicts an example of the Swiss cheese model using a prescribed medication moving through the layers of holes until the client is harmed. This model could be applied to any harm related to client care, not just errors in medication administration. This model focuses on the health care system rather than the individual in the occurrence of medical errors. Improving the safety of the client must begin with developing a culture of safety within the institution. The emphasis should be on working together as a team, collaborating with a focus on communication and client safety.

Figure 3.3 This version of Reason’s Swiss cheese model depicts how an incorrect medication may be given to a client. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Many institutions have begun the process of developing strategies to prevent or reduce the number of medication errors. Some strategies include (Tariq et al., 2023):

• Replacing handwritten orders with computerized order entry
• Rounding with the physician (pharmacist/nurse)
• Double-checking the dose of all high-alert medications with another provider
• Double-checking drug calculations
• Speaking with the pharmacist or looking the drug up in a resource if unsure about a medication
• Remembering that any drug has the potential for adverse effects
• Monitoring kidney and liver function
• Knowing high-risk medications
• Knowing the indication of a prescribed drug (if not known, then asking the provider)
• Order read-back and verification of verbal or telephone orders
• No use of abbreviations
• Providing clear, explicit instructions for each medication

Other potential strategies include:

• Bar code systems
• Instituting medication reconciliation at any transition in care

Some medications have an increased likelihood of causing harm to the client if administered incorrectly, such as potent blood thinners like heparin or insulin, which may cause a bleeding event or lethal drop in blood sugar, respectively. The ISMP has classified these drugs as “high-alert” medications. These are drugs that should have two providers verify the dose to be administered, and both nurses must document on the medication administration record (MAR) when these medications are given.

The ISMP has several strategies for the prevention of medication errors. Improving access to information about drugs is helpful to any provider. This may take the form of drug books or guides on the unit or access to relevant electronic resources. Another prevention strategy is limiting access to high-alert medications. Some high-alert medications, including neuromuscular blockers, are not needed on each hospital unit, so removing access to them on those units may help avoid dangerous drug errors. The more standardized the systems for ordering, storing, preparing, or administering medications, the less likely an error will occur. The electronic system has automated alerts to prevent errors (e.g., pop-up alerts to prevent administering a medication that a client is allergic to). “The responsibility for accurate medication administration does not lie with a single individual. Rather, it lies with multiple individuals, including organizational leaders, who are responsible for the design, implementation, and maintenance of reliable systems to support safe medication use for all practitioners” (ISMP, 2023).