Medication mix-ups, also known as medication errors (MEs), are some of the unfortunate happenings that occur in the medical field. MEs, according to Björkstén et al. (2016), are the most common type of medical safety incidents globally and cause harm to patients, distress to medical practitioners, and huge costs to medical facilities, yet only 5% of these incidents are reported. In Columbia, South Carolina, one of these unfortunate incidents happened and claimed the life of a veteran who had visited a medical facility for treatment.
One of the most recent ME incidents happened in the Dorn Veterans Affairs Medical Center where through acts of negligence or omission, according to Monk (2018), led to the death of an Air Force veteran named Ralph Keogh. Keogh had gone to the medical facility seeking medical help when a mix-up in syringes took place (Monk, 2018). Court records indicate Keogh had visited the facility, eleven days prior to his death, with vomiting and nausea (Monk, 2018). The medical staff administered multiple doses of pegfilgtastim to Keogh and his family stated he had actually been prescribed filgrastim leading to pulmonary toxicity and subsequent severe acute lung injury (Monk, 2018). After Keogh’s death, the federal government agreed to pay $800,000 to his relatives as settlement for the malpractice (Monk, 2018). This case is an example of how MEs can lead to fatal injuries in medical facilities and the need for medical doctors and nurses to find ways of reducing their occurrences.
Barcode administration is one of the strategies nurses and medical doctors at the Dorn Veterans Affairs Medical Center could have used to avoid the ME. According to Rodziewicz et al. (2018), barcode administration and the use of handheld personal digital assistants are effective in helping to increase administration and patient safety. These gadgets provide patients’ real-time and drug information and help reduce documentation errors. Research (Truitt et al., 2016) indicates the use of barcode administration by the medical staff could have helped reduce MEs by 50% and serious errors by up to 25%. These researches prove the effectiveness of the use of barcode administration in medical facilities as a way of reducing the occurrences of MEs. It is important for the medical facility’s staff to embrace the use of barcode administration in future when attending to patient to improve patents’ safety and prevent the occurrence of MEs.
Another strategy that would have helped avoid the ME is the use of color-coded systems. As seen in Keogh’s unfortunate case, a mix-up of syringes led to his death. Color-coding and correct labelling of the syringes, however, could have helped avoid the fatal incident. It is critical for the medical practitioner to write the name of the drug in a syringe for easy identification and a mechanism for avoiding MEs (Gariel et al., 2018). Gariel et al. (2018) continue by saying MEs can be avoided when the preparation and administration of drugs are done by the same medical practitioner who double-checks them. Through the use of this strategy, the Dorn Veterans Affairs Medical Center staff would have minimized the ME risk and its clinical consequences.
The primary role of the nurse in pharmacology is ensuring high-quality care for the patient. Research by Heczková and Bulava (2016) indicates nurses are required in pharmacology for medication management and the provision of high-quality care to their patients. It is the responsibility of caregivers to ensure the risks of MEs are minimized in a medical setting and there is improvement of patients’ outcomes. For instance, the nurse could take up the responsibility of clearly labelling syringes and drugs before they are administered to the patient. This strategy can greatly help reduce the occurrence of a medical error and improve the quality of care the patient receives. It is critical for nurses to receive more training on pharmacology and strategies for minimizing MEs risks.
