Writing Assignment #2:

Before submitting this assignment, be sure to read the assignment instructions here.

About 15,000 people die from dosage errors each year in America. About two-thirds of these deaths are children or infants. As a result, the health care industry is continually looking for ways to reduce medication errors. As you have already seen, many of the rules which have been established for reading, writing, and administering medicines have been chosen and continually updated to address this issue.

Your Assignment:
Below is an excerpt taken from an article on a study done to evaluate errors during the administration of IV medication.

Use of Failure Mode and Effects Analysis in Improving the Safety of I.V. Drug Administration

Posted 05/16/2005

Wayne Adachi; Amy E. Lodolce

Abstract and Introduction

Abstract

Purpose: Failure mode and effects analysis (FMEA) was used to identify dosing and administration errors associated with i.v. medications and evaluate the effectiveness of subsequent system improvements.
Summary: A multidisciplinary medication safety team conducted an FMEA to identify and reduce common medication errors and selected wrong-dose errors for process improvement. In 2002, wrong-dose errors comprised 17% of all medication errors at the hospital (59 of 347 errors). The most common reason for administering the wrong dose was error in programming the i.v. infusion pump (41%). Potential errors (i.e., failures) identified were misinterpretation of the order, removing the wrong medication or wrong concentration of the correct medication, using the wrong diluent or drug to prepare the drip, and entering the wrong concentration or infusion rate on the pump. Errors in programming the i.v. infusion pump was the step in the medication-use process associated with the highest criticality index. Based on the results of the FMEA, two main interventions were performed. First, standard order sets were revised after streamlining the formulary and eliminating the use of unapproved abbreviations. Second, an i.v. pump with enhanced safety features was implemented. One-year follow-up data revealed that the number of medication errors related to dosing (wrong dose or incorrect infusion rate) had decreased slightly (from 59 in 2002 to 46 in 2003); however, a dramatic reduction was noted in the percentage of pump-related errors. In 2003, pump-related errors accounted for 22% of dosing errors, compared with 41% in 2002.
Conclusion: Medication errors related to i.v. infusion pumps were reduced by conducting an FMEA and implementing the process changes needed.

Introduction

The Institute of Medicine's report on the safety of the health care system confirmed what many practitioners believed -- medical errors occur frequently, are costly, and negatively affect patients' quality of life.[1] Medication errors are believed to be responsible for about 7000 deaths each year in the United States. Furthermore, patients who have preventable adverse drug events (ADEs) while in the hospital have increased morbidity, resulting in increased length and cost of hospital stay. Estimates project that $2 billion of increased hospitalization costs is attributable to preventable ADEs. Medication errors can occur with any route of administration; however, patients receiving i.v. medications are at particular risk, since many high-alert medications (e.g., heparin, insulin, and opioids) are administered intravenously.[2,3]

Am J Health-Syst Pharm.  2005;62(9):917-920.  ©2005 American Society of Health-System Pharmacists

Consider each of the following statements taken from this article above:

  1. The most common reason for administering the wrong dose was error in programming the i.v. infusion pump (41%). Potential errors (i.e., failures) identified were misinterpretation of the order, removing the wrong medication or wrong concentration of the correct medication, using the wrong diluent or drug to prepare the drip, and entering the wrong concentration or infusion rate on the pump. Errors in programming the i.v. infusion pump was the step in the medication-use process associated with the highest criticality index.
  2. Medication errors can occur with any route of administration; however, patients receiving i.v. medications are at particular risk, since many high-alert medications (e.g., heparin, insulin, and opioids) are administered intravenously.

Then, write a 2-3 page essay which addresses the following questions:

  1. Give an example of each of the types of errors listed in Statement A above. You can use examples from the homework problems or lecture examples to come up with these examples, if that helps.
  2. Consider Statement B above. What do you think they mean by "high-alert" medications? (You may want to read about Insulin and Heparin before answering this question.) Can you explain why errors in "high-alert" medications may be more serious than other errors? Give examples of specific drugs and order mistakes to illustrate your explanation.

Again, your essay should flow smoothly - don't just answer each of the questions - be sure to write so that your essay makes sense as a whole.

Also, write as though you were explaining these issues to a friend who is not taking this class; simple, clear language is best, and if in doubt, explain something before you discuss it.

You will submit this assignment under the "Writing Assign." button on the main course webpage.

Once you have submitted this assignment, you will be required to read the essays of 3 fellow students and to give each of these classmates feedback on their essays; the deadline for this feedback is one week from the deadline for this assignment. You will only be able to view other student essays once the deadline for submitting your first draft has passed.

Then you will have one week to revise this assignment and resubmit it before I assign a final grade.