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Critical Thinking in Addressing Dispensing Errors

Dispensing errors are common and most of them, often, go undetected when dispensing drugs in the hospitals and the pharmacies. The errors may occur at any stage during the dispensing process which begins with the receipt of a prescription and ends with the release of the drug (Leung et al. 89). When these errors occur, they result in a patient’s lack of confidence in the entire healthcare fraternity, and an escalation of litigation procedures.

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The errors include wrong drug selection when two or more drugs have the same appearance or similar name. The errors may also result when the drug is dispensed to the wrong patient or when a wrong drug or wrong dose is given to the patient. This paper will discuss ways of enhancing patient safety by readressing the occurrence of administration errors.

Administration errors result from altering the drug administered, and associated dosage, and route used. The administration errors comprise the omission errors attributed to the mismatch of patients and lack of stock (Cohen 205). The following scenario is an example of an incident that occurred within the healthcare facility, but I have devised mitigation approaches to avoid similar incidences in the future.

Mr. Samuel had a history of kidney disease which led to his admission to the intensive care unit (ICU) after a dialysis session. The patient had experienced severe shortness of breath. Mr. Samuel complained of an upset stomach after admission. Doctor Mark, who attended Mr. Samuel on that day, prescribed an antacid to be administered to the patient. The nurse, who was given Mr. Samuel’s prescription, unfortunately, administered pancuronium instead of antacid.

Pancuronium, a drug that acts as a muscle reluctant and paralytic during intubation, led to respiratory arrest and rendered Mr. Samuel unresponsive. Although the doctors managed to revive Mr. Samuel, he ended up with a dead brain. After an interrogation was done, the nurse said that the packaging of the pancuronium looked the same as that of antacid and that’s why he ended up picking the wrong package.

The unintended outcomes which affected Mr. Samuel resulted from wrong drug administration. According to Lane and Feldman (233), the occurrence of such errors could be reduced through bar-coded medication administration (BCMA) systems. Clinical officers providing administrative services at the bedside should scan the bar code on their identification tags, the patient’s identification bracelets, and the unit dose to be administered as required by the bar-coded medication administration system.

According to Agrawal (683), the scanned information makes the system alert the specific clinical officer of any patient’s mis-identity or any mismatch in the route of administration, dose, and even the drug. The bar-coded medication administration system ensures that the right dose of the right drug is administered to the right patient and the right route of drug administration is used at the right time. The system implementation improves the drug administration accuracy and generates online medical records of the patients. This system also provides accurate and complete documentation of the medication administration process.

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Automated drug dispensing cabinets used in the health centers store the drugs and dispense them at the clinical points of care. The cabinets also control and track drug distribution. The use of the cabinets reduces the dispensing errors through packaging, dispensing, and recognizing each medication using the available bar codes (Tsao et al., 140). The bar code recognition by the cabinets distinguishes several drugs with similar names and appearances. The documented drug prescription about the patient’s health is done in electronic formats and linked to the dispensing cabinets thus, solving the issues of wrong drugs or dosages.

The main goal of every pharmacist is to avoid and minimize the dispensing and administration errors during the medication process. Montesi and Lechi (651) suggest that epidemiological knowledge, error detection, and improvements in performance form a basis in the development of key strategies necessary for the prevention of medical errors.

Works Cited

Agrawal, Abha. “Medication errors: prevention using information technology systems.” British Journal of Clinical Pharmacology 67.6 (2009): 681-686. Print.

Cohen, Michael R. Medication Errors. Washington, D.C: American Pharmaceutical Association, 2007. Print.

Lane, Philip, and Jeffrey M. Feldman. “Legal Aspects of AIMS.” Anesthesia Informatics. Ed. Jerry Stonemetz and Ruskin Keith. London: Springer, 2008. Print.

Leung, A., C. Denham, T. Gandhi, A. Bane, W. Churchill, D. Bates and E. Poon. “A safe practice standard for barcode technology.” Journal of patient safety 11.2 (2015): 89-99. Print.

Montesi, Germana, and Alessandro Lechi. “Prevention of medication errors: detection and audit.” British Journal of Clinical Pharmacology 67.6 (2009): 651-655. Print.

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Tsao, Nicole W., Clifford Lo, Michele Babich, Kieran Shah and Nick J. Bansback. “Decentralized Automated Dispensing Devices: Systematic Review of Clinical and Economic Impacts in Hospitals.” The Canadian Journal of Hospital Pharmacy 67.2 (2014): 138–148. Print.

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