How can I fix errors using NMC guidesJuly 18, 2020 by Henry Alderson
If you received a medication error code for the NMC guidelines, this post was written to help you.
Five rights of drug administration. One of the recommendations to reduce mistakes and harm when taking medication is to use the “five rights”: the right patient, the right medicine, the right dose, the right way and the right time.
As we saw in the previous columns, errors in taking medications pose a high risk to patients. Most medical professionals, especially nurses, are aware of the “five rights” to drug use: the right patient, the right medicine, at the right time, in the right dose and in the right way - all this is widely considered the norm of drug safety. However, many mistakes occurred, including fatal ones, even if medical workers were sure that they confirmed these “rights”. Why is this happening?
First, although these criteria are the goals of safe drug practice, they give little advice to medical professionals on how to adequately ensure the safety of drugs. For example, how does a pharmacist identify a suitable patient if their name and room number on a copy of the prescription are unclear and the doctor’s signature is illegible? Who should I contact your pharmacist for further care? How does a home nurse identify a suitable patient in a care facility if name bracelets are not used? Can a nurse countShave the patient orally? Unfortunately, relying on accurate patient information leads to errors, for example, when patients misunderstood the name or when they were confused.
As already mentioned, the five rights are human-oriented and do not reflect the fact that drug safety is the culmination of the efforts of experts from various disciplines. Several people and reliable systems are responsible for the accurate delivery of drugs. Factors that could prevent a medical team from exploring five rights, despite all their efforts:For example, nurses cannot verify a patient’s identity if they cannot know if the patient is really saying what they are saying, or if the name on the patient’s cuff is correct. You can check only two unique identifiers that were assigned to the patient upon entering the facility — a process that the organization considers sufficient to confirm the patient’s identity — before the medication is administered. Similarly, nurses and pharmacists cannot confirm that the right medicine is in a specific tablet or bottle orthen it contains the right dose and the right dose. However, they may be responsible for the following steps: Organizations consider these rules of procedure sufficient to verify the correct treatment and dose. Therefore, the doctor’s duty is not to exercise the five rights, but to follow the procedures established by the organization to achieve these results. If the procedural rules cannot be followed due to problems in the system, doctors are also required to report the case so that it can be resolved.
Although some consider this difference to be insignificant, it is worth considering the following points. When we hold people accountable for the realization of the five rights, we must enable them to develop their own systems to achieve these results. How can we hold people accountable for situations and events that are not under their control? However, since organizations usually decide the processes necessary to exercise the five rights, employees who follow these procedures should not be held personally liable for undesirableresults. The systems themselves should be improved, not human practice or behavior. Five rights are not behaviors for drug safety. These are the goals for which companies should take responsibility and develop safety methods so that these goals can be achieved.
Of course, five rights is not the last word about drug safety. Unfortunately, managers often reprimand doctors for a mistake, because they do not respect the five rights without recognizing and processing human factors and the causes of errors that occur in the system. Similarly, regulators often punish health workers for failing to review the five rights. Such actions confirm the belief that people should be blamed. Five rights should remain targets for drug use, but we must help practitioners achieve these goals by creating robust support systems that promote safe practices.
- midwifery council
- professional issues
- drug administration
- medication administration
- double checking
- contributing factors
- medicines management
- al salam
- patient safety
- nurses perceptions
- decision tree
- nmc healthcare
- Common Error Medication
- Error Medication Prevention
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