Medication Errors Reporting at Community Memorial Hospital
Atueayu D. Wilson
Mid-America Christian University

Introduction to Health Care Management HCA 3203 06W1
Professor Ed Schmitz
19 June 15

Medication Errors Reporting at Community Memorial Hospital
The core issue for this case is medication errors. Nurses in the hospital are carelessly giving their patients the wrong medication and not reporting it correctly, if at all. Instead of all the units reporting incidents simultaneously, they each had their own method which was a problem within itself, because when it is time to send the reports up to the VP of Nursing, she has to sort through them and figure out what each one means. Furthermore, the staff was also incorrectly trained to report the errors as needed. Instead of the report forms going into detail, they are vague which causes ill-defined incidents. A brief report is problematic because if it needs to be researched at a later date for whatever reason, it will be hard to determine what happened and there is also a high chance the nurse who reported it doesn’t remember exactly what happened that night due to seeing so many patients on a daily basis. The weekend staff seems to be an issue as well. They are reporting less than the crew working during the week. Although nursing plays a role in this issue, they are not the only party to place blame.
Many medication errors come from prescribing errors. Either the physician ordering the medication prescribed a certain medication for off-label use, misdiagnosing the patient’s illness, miss-prescribing, or even over prescribing a certain drug can eventually lead to detrimental health effects. There are even some doctors who prescribe certain medications for advertisement to benefit thyself. Hospital pharmacies can also cause medication errors by filling the floor’s medication machine with the wrong medication by mistake. For example, if a physician requests an order for their patient to have the medication Depakote 500mg E.R. once daily for epilepsy and the technician fills the medication machine with Depakote 250mg E.R., the patient will receive an inadequate dose. The result of this error can be devastating to the patient because his seizures will not be controlled properly. Insufficiently handling medication also costs the hospital thousands of dollars each period. With that being said, the floor nurses are the last line of defense (if you will) to ensure the patient is taking the proper medication and strength. It is their job to double check the patient charts in case the physician has discontinued or changed drug. However, there are steps to take to help elevate these mishaps.
As stated in the case study, the policy and procedures are out of date (Williams and Savage, 2007). The first step to eliminating medication errors will be to revamp the policies and procedures of handling the reports. Have a meeting with all the staff involved to gather as much information and insight on how they would better the policy and procedures since they are the people with hands-on experience. Along with updating that, upgrade the report error forms with more depth. Redo them as to where the staff is aware of exactly what is needed when an error occurs. Also, because this is a costly expense, make room in the hospital budget to purchase up-to-date Pyxis MedStation system with scanning features to replace old medication machines throughout the hospital in an adequate time. Pyxis is a medication machine that holds numerous amounts of different medications in little cubbies and is easily available to nurses in the medication room. They can access it by either using their fingerprint or employee I.D. This