Adverse Medical Events Related to Medication Errors

Adverse Medical Events Related to Medication Errors
Medication errors and the associated adverse medical events are common in hospitals. Nursing students are highly likely to cause adverse medical events related to nursing tasks during nursing placements. An adverse medical event risks delivering high-quality healthcare services (Alhassan et al., 2019). 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 medicine (Agency for Healthcare Research and Quality, 2019). An adverse drug effect is a 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 Placements
Medication errors are preventable and could cause patient harm, inappropriate medical usage, mortality, and morbidity (Dreijer et al., 2018). During nursing placement, a nursing student experienced an adverse drug event related to the wrong dosage. 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 appropriately, a bleeding complication, among other complications, could cause death (Warnock & Huang, 2020). The usual adverse effects of high heparin administration include injection site reactions, nosebleeds, bruising, black stools, severe bleeding, and hyperkalemia (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. 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 nurse administered a higher amount of heparin infusion, which caused hyperkalemia. In this case, the involved health provider was a nurse who administered the patient the wrong dosage of anticoagulant heparin.
Impacts of High-Heparin Infusion
The effect of high-dose heparin administration on the man was elevated serum potassium. Increased serum potassium levels due to high heparin infusions were managed and resolved after heparin administration was discontinued (Kovacs et al., 2022). Elevated serum potassium level associated with heparin infusion gradually returns to the expected blood potassium level following the discontinuation of treatment. In the man's case, the nurse stopped heparin treatment since an 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 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 reverse and manage the bleeding complications of high heparin dosage (Smythe et al., 2016).
Implications of Adverse Events
Medication errors are costly to stakeholders such as healthcare providers, patients, families, and hospitals. Wondmieneh et al. (2020) reported that nurses are severely impacted by emotional distress, guilt, loss of patient trust, and punitive actions of possible lawsuits and loss of practicing licenses. Based on the assumption that the involved health provider feels guilty, they can face the long-term impact of suicide. Patients experience short-term consequences of additional hospital stay, increased costs, and long-term effects of permanent injury, mortality, and morbidity (Wondmieneh et al., 2020). A systematic review of medication errors in African hospitals reflected that 8.4% of patients experienced adverse drug events, 0.1% mortality rate, and 0.77% extended hospitalization (Wondmieneh et al., 2020). Health institutions suffer from increased costs for correcting medication errors (Wondmieneh et al., 2020).
The Sequence of Events Related to the Adverse Events
A root cause analysis gives a systematic and structured approach to evaluating medication errors (Abreu, 2021). During the nursing placement, the nursing student administered a high heparin dosage since the supervising nurse was negligent for failing to give complete dosage details and not supervising the student. Specifically, the student needed the correct volume and hourly rate for heparin administration. The people aspect was the root cause of administering the wrong dosage. The inadequate experience and training made the nursing student unable to calculate the correct dosage. Further training and nursing experience can improve the student’s future heparin administration. In the 77-year-old-man case, as Kovacs et al. (2022) reported, the high heparin infusion occurred because the nurse failed to double-check the concentration administered. Nevertheless, the root cause of the medication error was that the pharmacist had inadvertently handed out an incorrect heparin concentration. A lack of double-checking and verification prevented the nurse from noticing the wrong concentration. The pharmacy process was the patient’s root cause of heparin-induced hyperkalemia. Analyzing the unanswered questions of why the pharmacist accidentally handed out the wrong concentration of heparin would help prevent such medication errors.
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, and not following guidelines and protocols (Dreijer et al., 2018). According to WHO (2017), medication errors occur due to inadequate experience and training, burnout, and communication issues. The patient could develop a new condition, such as skin disfigurement, rashes, and severe injury (Dreijer et al., 2018). These metrics related to medication errors support the need for improve...