Adverse Medical Events Related to Medication Errors

Adverse Medical Events Related to Medication Errors tudent’s Name Institutional Affiliation Course Code and Name Instructor’s Name Date Due
Adverse Medical Events Related to Medication Errors Medication errors and the associated adverse medical events are common in hospitals. During nursing placements, nursing students are highly likely to cause adverse medical events related to the nursing tasks they ought to perform. An adverse medical event risks delivering high-quality healthcare services, especially in poor hospital settings (Alhassan et al., 2019). Many medication errors lead to the occurrence of adverse drug events. A medication error is an omission or commission error that occurs at any point along the path that starts when a physician prescribes a drug and ends when a patient gets the prescribed drug (Agency for Healthcare Research and Quality, 2019). An adverse drug effect is harm caused to a patient due to exposure to the wrong medication (Agency for Healthcare Research and Quality, 2019). Alhassan et al. (2019) reported that adverse medical events cause 30% of deaths in sub-Saharan Africa, and many of these go unreported. This paper aims to analyze adverse medical events related to medication errors in hospital setups.
An Adverse Event during Nursing Placement
Medication errors are among the most common medical errors that lead to significant mortality and morbidity. Such errors are preventable and could cause patient harm or inappropriate medical usage (Dreijer et al., 2018). During professional nursing placement, a nursing student experienced an adverse drug event related to the wrong dosage during drug administration. The student administered a high intravenous anticoagulant heparin, leading to bleeding complications. They failed to safely use heparin, which needs weight-based dosing and frequent tests to monitor blood clotting (Warnock & Huang, 2020). Abnormal laboratory results detected an overdose of heparin. As a result of the high dosage administration, the patient died due to bleeding complications, hence an adverse medical event.
The Adverse Event in Other Facilities
In other facilities, medication errors related to administering high doses of intravenous anticoagulant heparin occur in the inpatient setting. If a clinician fails to respond quickly and appropriately, the impact is a bleeding complication, among other complications, which could cause death (Warnock & Huang, 2020). The usual adverse effects of high and chronic heparin administration include injection site reactions, thrombocytopenia, blood in stools or urine, nosebleeds, easy bruising, black stools, continuous and severe bleeding, hyperkalemia, osteoporosis, alopecia, and petechial rash (Warnock & Huang, 2020).
In a study conducted in a specific hospital setting, Kovacs et al. (2022) reported that a 77-year-old man experienced adverse effects of heparin-induced hyperkalemia. Initially, the man presented with shortness of breath and a productive cough. He was later found to have concomitant symptomatic COVID-19 disease and a non-ST-elevation myocardial infarction. His condition necessitated a prescription and an infusion of high-dose unfractionated heparin. The clinician prescribed the appropriate high dose of anticoagulant heparin based on the patient's weight and needs. Nevertheless, the attending nurse administered a higher dose of heparin infusion, which caused hyperkalemia or a high potassium level in his blood. In this case, the involved health provider was a nurse who administered the patient the wrong dosage of anticoagulant heparin. The root cause of administering the higher heparin dose was a lack of double-checking of the amount to be administered.
Impacts of High-Heparin Infusion
The effect of high-dose heparin administration on the man was elevated serum potassium. It is necessary to stop heparin treatment to enable the reversal of the elevated serum potassium level. Increased serum potassium levels due to high heparin infusions were managed and resolved after heparin administration was discontinued (Kovacs et al., 2022). Typically, the elevated serum potassium level associated with heparin infusion gradually returns to the expected blood potassium level following the discontinuation of heparin treatment. In the man's case, the decision to stop heparin treatment was made since the patient's evaluation revealed that he was not using any other drug that led to hyperkalemia (Kovacs et al., 2022).
Managing Heparin-Induced Complications
In other facilities, major bleeding complications associated with high heparin dosages are reversed and managed through the administration of protamine sulfate (Smythe et al., 2016). It is, therefore, necessary to administer 1 mg of protamine for every 100 units of heparin to manage the bleeding complications. Since heparin has a short half-life, the amount of heparin administered in the past few hours is considered when determining the dose of protamine. Nevertheless, 25 mg of protamine is administered during emergencies to reverse and manage the bleeding complications quickly (Smythe et al., 2016). When indicated, protamine sulfate should be used to reverse and manage the effects of high heparin dosage. It helps resolve the bleeding complications associated with administering a high heparin dosage (Smythe et al., 2016).
Implications of Adverse Events
There are various implications related to medication errors and adverse medical effects for all stakeholders. Nurses or doctors who experience a near-miss or accidentally administer or prescribe the wrong medications to patients could experience self-doubt, guilt, or shame. It is regarded as the "second victim syndrome," which could cause severe effects like suicide and loss of patient trust. Another implication for the healthcare personnel and the hospital is a possible lawsuit from the family members following a medication error. The personnel could also lose their practicing license as a punitive action (Wondmieneh et al., 2020).
The Sequence of Events Related to the Adverse Event
Dreijer et al. (2018) found that anticoagulation medication errors occur during the prescribing and administering phases of the medication pathway. 53.5% of the cases were associated with human factors, including performance deficits, not double-checking the dosage to be administered, and not following guidelines and protocols (Dreijer et al., 2018). According to WHO (2017), medication errors occur due to inadequate experience and training, burnout, fatigue, and communication issues. Various metrics for medication errors and the associated adverse events necessitate improvement initiatives. Medication errors like high-dose administration c...