How do I respond to the following posts (each post

How do I respond to the following posts (each post separately). Please provide a list of references no older than 5 years old. Thank you. Post 1 – Marjory: Concept Analysis Competency Assignment #2 RCA What were the failure points? Failure points included the incorrect intravenous medication that led to the incorrect dosage administration. The registered nurse (RN) discontinued the dobutamine and hung the amiodarone as prescribed. The amiodarone was hung in a timely fashion below and next to the dobutamine. This creates a potential risk factor for selecting the incorrect medication to administer. This is identified as a lapse error. Shortly after hanging the amiodarone the nurse was distracted and turned away to address a question that was posed to her. This is another point of failure. She should have completed the task at hand instead of addressing the question. The RN could have simply stated give me a few minutes I will be right with you. The distraction led to a bolus of 600 cc of dobutamine in 5 minutes rather than the prescribed amiodarone. How could this error have been prevented? The dobutamine should have been removed from the intravenous (IV) pump in current use. The 5 rights of medication administration (the right patient, drug, dose, route, and time) should have been reviewed prior to starting the infusion. Medication barcode and patient wrist band scan should have been reviewed prior to dosing the infusion pump and starting the medication. The RN could have verified that the correct medication was being administered through double checking with another clinician. What processes could be put into place to prevent this type of error in the future – be realistic. Double checking system involving 2 clinicians to confirm that the 5 rights of medication administration were correct should have been implemented. This strategy or time-out session prior to IV medication administration allows for a pause and verification that all relevant information affords staff the opportunity to double check without feeling rushed. The barcode system scanning procedure ensures that the medication being administered is the correct medication prescribed in the electronic health record. Clear colored bold labeling with the name of the medication, the dosage, and the expiration date on IV bags help prevent errors. Implementation of smart infusion pumps that are programmed with drug libraries that flag incorrect dosages or rates. Creation of a standard protocol for administration of high-risk medications with listed strategies for administration. Implement a non-punitive error reporting system encouraging staff to report near misses and actual errors without fear of retribution. Have you ever made a medication error? I recall programming a heparin IV pump with the incorrect dosage. The night nurse that I handed the report to recognize the error and took the appropriate measure to correct it. The nurse manager and on call physician were informed and the recourse was implemented. How did you feel and how were you treated? I was devastated and distressed to say the least. I reviewed the scenario repeatedly in my head and I just did not know how I could have made an error that could have harmed my patient. I believe the very next day I traced myself and walked through what occurred the day before. I just could not understand how I could have made such a grave mistake. I was embarrassed and felt inept. I was thankful that the patient was not harmed. My manager was a true leader. She spoke to me with much grace. I reviewed the protocol for administering IV medications and conducted research on the prevention of IV medication errors. I was able to present my findings to the unit staff for continued edification. I will never forget that mistake. What should happen to the staff involved? This incident created an opportunity to provide ongoing training for all healthcare staff on medication administration and safety measures. The RN should be supported, and focus should be on patient safety. I recall a nurse on another unit that also made a medication error. The intense effect on the psyche can be so immense and unbearable. The nurse committed suicide a few days later. I did not know the nurse personally, but I saw her in passing. My heart ached for her knowing exactly what she went through. Emotional support should be offered through employee assistant program (EAP) counseling. Peer support is an additional strategy to help deal with the emotional aftermath providing the much-needed support to the clinician. Ensuring that constructive training or education takes place focusing on learning rather than punishment to prevent future errors. Examine and incorporate literature and evidence-based practices on human error and Just Culture. While the exact number of deaths in the United States as a result of medical errors remains controversial, what is clear is that underreporting is a common and challenging impediment to improving patient safety (Murray et al., 2023). Stewart et al. (2020) estimates that these errors cause at least one death every day and injure approximately 1.3 million people annually in the United States (US) alone. A just culture focuses on learning from errors rather than ostracizing, blaming, or making the individual feel less than. This entails creating an environment that does not concentration on punishment rather, shifting the focus in creating a safe space where the nurse feels comfortable reporting errors in turn allowing the improvement of systems and processes to ensure patient safety. The just culture promotes accountability acknowledging that errors occur because of system failures rather than personal negligence distinguishing between human error, at-risk behavior, and reckless behavior. This allows for the appropriate response to be executed. Post 2 – Janella: Failure Points Many issues at the hospital led to the initial failure and subsequently medication errors. Based on the case presented, it included nurse interruption when programming the Amiodarone pump, which led to the programming the Dobutamine medication pump. Interruptions during medication administration can lead to an increase in the potential for errors in administering medications. High-stress environments, like the intensive care unit (ICU) and emergency department (ED), can lead to a higher rate of medication errors when practitioners are distracted during procedures (Tsegaye et al., 2020). In addition, both dobutamine and amiodarone were hung on top of each other and the proximity of two medications contributed to the nurse’s interruption when programming the medication pump leading to medication error. There were no clear visual cues between the two medications, making it more accessible for the nurse to bolus the wrong medication. Furthermore, there was no secondary nurse in place to verify the medications. In high stress environments like the intensive care unit (ICU), where medications are frequently titrated, and patients’ conditions can rapidly change, the absence of a double verification step heightened the risk of errors. Prevention Strategies and Process Improvements Many measures could be taken to ensure such an error does not happen again. First, the hospital needs to implement policies to reduce work interruptions when administering special or high-alert drugs such as, in this case, dobutamine and amiodarone. Wang (2021) highlighted that ninety percent of interruption cause a negative outcome leading to medication errors. There should be a “no interruption zone” policy for nurse that could help prevent mistakes made when administering medications. Furthermore, the hospital could use intelligent pump technology for long-term process improvements, including built-in safety features. Safety features in the IV pump help nurses confirm that the correct medication is being administered at the right rate. These smart pumps can include drug libraries and alarms that prompt nurses to double-check their programming before administering any bolus medication. A literature reviewed by Alamer and Alanazi (2023) concluded that smart pump technology that has safety features improves safe administration and prevention of medication error by declining error rates of programming. For easier identification during medication administration using the IV pumps, pharmaceutical labels should use color-coded tags. IV pumps should be positioned in different locations to ensure they are visible and less likely to cause mistakes. Pinkney et al. (2019) highlighted that implementing labeling the lines or having an organizers can improve the accuracy and efficiency of infusion identification. This is to enhance visual communication, such as clearly identifying infusion contents and access ports. Establishing a policy that medications must be hung in designated areas or with visual separation will make it easier for staff to identify the correct medication. Another precaution would be installing double verification methods for the drugs and administration processes. Nurses must verify high-alert medications before administration through a dual sign-off mechanism to prevent medication errors. Furthermore, patient details and health conditions would also be reviewed before medication administration. This process, particularly when administering medications like amiodarone, could ensure that an additional layer of verification occurs before the medication is administered. While such steps might seem time-consuming, they are essential for patient safety, especially in high-risk environments like the ICU. Finally, nurses should be provided with simulation-based training for nurses on how to handle high-pressure and high-distraction scenarios in their work environment to reinforce the importance of double-checking mechanism medications and following standard protocols. Staff Handling and Just Culture The nurse involved in this medication error should be responded to by the Just Culture principles, which view mistakes as chances for growth rather than as grounds for punishment. A just culture promotes open reporting and transparency while acknowledging that most mistakes are systemic rather than personal. In this instance, the nurse should review the procedure to determine if systemic problems—like the interruption, incorrect labeling, or absence of a double-check system—were responsible for the error (Fordyce et al., 2020). The emphasis should be on improving training, redesigning the system, and ensuring that the surroundings encourage safe practice rather than imposing penalties. Just Culture emphasizes that when healthcare staff feel supported and are not afraid of being blamed, they are more likely to report errors and near-misses, which helps organizations identify potential hazards and make proactive changes to prevent future errors (Robichaud & Vittone, 2023). Human Error and Evidence-Based Practices Research on human error indicates that errors in healthcare are inevitable, especially in high-stress environments like the ICU and ED. A study by Schroers et al. (2021) indicates that healthcare professionals are prone to making errors when they are stressed, tired, burnout or distracted. Human error can be lessened by implementing evidence-based procedures, such as proactive risk assessments, frequent simulation training, and team debriefings following incidents. It is consistent with the principle of a Just Culture to prioritize systemic reforms over individual punishment, as this creates an atmosphere in which mistakes are viewed as teaching moments (Vahidi et al., 2020). By understanding the underlying causes of human error and implementing these strategies, healthcare organizations can significantly improve patient safety and reduce the likelihood of similar incidents. Post 3 – Adrianna: In the healthcare environment errors can occur due to the high complexity of certain specialties, leading to an abundant occurrence of adverse/undesired events (Frazão et al., 2022). “Human error” can happen by mistake, but the way an organization handles the situation is when it may become tricky. According to the Institute of Medicine, a report stated that up to 98,000 people die every year due to medical errors that occur in healthcare settings (Barkell et al., 2021). Just culture is a balanced system that is being implemented across healthcare fields. This system aims to achieve fair conclusions to events that can occur and focuses on openness, repairing harm, and learning from events (van Baarle et al., 2022). Just culture has prompted many healthcare workers including myself to report incidents that may have occurred within my shift so we as a unit can learn. In this instance, there was a lack of communication, inadequate medication management, and programming failure. Due to the fact that the amiodarone and dobutamine were hung next to each other and there was no clear labeling of lines and IVs. Also, the similarity of IV bags and IV pumps could have caused confusion. A strategy that can be implemented in the CVICU and in any unit to help reduce the risk of confusion is medication labeling and placement—ensuring that the IV bags for medications are clearly labeled and medications are placed in an appropriate neat manner to be able to identify. Another important strategy to help with this situation is improvement in communication protocols. At my hospital when a nurse is dealing with any medications the phone is placed on do not disturb as well and no nurse should speak to them while hanging medications. If the hospital establishes a protocol to handle interruptions during medication administration this may help to decrease medication error. I have not made a medication error, but I have heard of my coworkers making an error. All healthcare professionals who have made a medication error often experience many emotions ranging from guilt to stress, and anxiety. A medication error is always a learning experience to help improve bedside care. All staff involved in the event should be provided with support and teaching. The incident should always have a thorough review done and help all focus and understand how the error occurred and what can be done to prevent future occurrences.

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