Medication Error Disclosure Personal Experience

Medication errors occur frequently due to human error. Disclosing errors to patients can have positive ramifications. This paper will start with the personal experience of the writer regarding medication errors. Then, the legal aspects as well as the ethical aspects of disclosing medication errors will be discussed. Lastly, prevention strategies will be reviewed.

It was 1994 and I just passed the last written nursing licensure test. I was hired to work the night shift on the oncology floor in a Chicago hospital.

I remember introducing myself to the patient and letting him know that he was going to receive a blood transfusion. At that time, there was not a verification process by two nurses. I hung the blood and started the pump. Before I left the room, I checked the bag one more time and realized it was it was the wrong patient. I immediately stopped the transfusion and let the patient know that I will be right back. I informed my charge nurse who accompanied me back to the patient’s room.

She explained the error and reassured the patient that we would work on preventing errors like that from recurring. I apologized and the patient was understanding. I was lucky because the small amount of blood the patient received did not cause an adverse event.

The IOM safety report in 1999 revealed that three percent of hospitalized patients experience an adverse event (Guillod, 2013). Of that percentage, ten percent die due to the adverse event (Guillod, 2013). These adverse events are not a result of negligence or incompetence.

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Rather, the cause is that a higher standard of care has not been achieved (Guillod, 2013). It is the responsibility of those involved in healthcare to ensure a higher standard of care (Guillod, 2013). As a nurse practitioner, it would be my responsibility to disclose medication error not only to promote trust but also to ensure error will be prevented in the future.

The question of whether the law improves patient outcomes was broached by Guillod (2013). The law should serve two purposes which are to recompense the victim and to prevent future injury (Guillod, 2013). Civil lawsuits compensate the victim but does nothing to prevent future injury (Guillod, 2013). In addition, the law reinforced denying medical error (Guillod, 2013) In order to mitigate future injury, disclosure laws have been formulated (Guillod, 2013). The disclosure laws aspired to improve professional behavior (Guillod, 2013).

The challenge of the disclosure laws was persuading the stakeholders to revamp the process they have used in the past and to develop new processes that encourage disclosure (Guillod, 2013). For the law to succeed, modifying professional behavior through training, incentives, and a critical incident reporting system (CIRS) needed to be implemented (Guillod, 2013). A study by University of Michigan Health Systems proved that disclosing medical errors were cost effective which may motivate stakeholders to develop new processes (Guillod, 2013).

The National Quality Forum recommended a guideline on disclosure of adverse events. The guideline suggests patients are notified of consequences of adverse event, reassurance that error will be investigated, and patient will be notified of progress of investigation (Westrick and Jacob, 2016). Additionally, the guidelines suggest the healthcare provider express remorse for adverse event (Westrick and Jacob, 2016). These suggestions are evidence-based and supported by The Joint Commission, Institute for Healthcare Improvement, Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services (Westrick and Jacob, 2016).

In California, the Apology Law supports disclosure. The law asserts that statements, whether verbal, written, or gestured, indicating sympathy or empathy about the pain, suffering, or death associated with an adverse event to the patient or relative cannot be used as evidence (California legislative information, n.d.) Furthermore, admitting fault with relation to that statement also cannot be used as evidence (California legislative information, n.d.).

Adverse event is defined by California as injury or death caused by a medication error in dose, drug, patient, time, rate, preparation, and route (California legislative information, n.d.). California law requires health facilities to report adverse events to the state department within five days of occurrence (California legislative information, n.d.). In the event the occurrence is dire; the healthcare facility has 24 hours to report the occurrence (California legislative information, n.d.).

Per Sorrell, nursing ethical principles of autonomy; beneficence and non-maleficence; and veracity support medical disclosure (2013). Autonomy is the ability of the patient to make an informed decision which could only be accomplished with full disclosure including adverse events due to medication errors (Sorrell, 2017) Beneficence is the responsibility to ensure the care received is beneficial whereas non-maleficence is the responsibility to ensure the care received is not harmful (Sorrell, 2017). Disclosing a medication error fulfills both beneficence and non-maleficence because safety and improved patient outcomes can result through disclosure as well as establishing trust (Ghazal, Saleem, Amlani, 2014) The ethical principle of veracity is the moral obligation to provide the truth (Sorrell, 2017). Thus, disclosure of medication error is supported by the ethical principle of veracity.

The America Nursing Association Code of Ethics for nurses also supports disclosure. Specifically, provision three of the Nursing Code of Ethics states that “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.” (American Nurses Association, 2015, p.9). This provision directs nursing professionals to establish an environment of safety. Disclosing medication errors promotes safety by addressing the error and developing process that prevent the error from being repeated.

Another provision of the Nursing Code of Ethic that supports disclosure is provision 4 that states “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care” (American Nurses Association, 2015, p.15). Disclosing medication errors demonstrates accountability and a desire to improve processes to improve patient outcomes.

Lastly, provision 5 of the Nursing Code of Ethic states “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.” (American Nurses Association, 2015, p.19). Fear of liability may influence a nurse practitioner not to disclose error. This provision encourages nurses to care for themselves by striving to keep their character unblemished which necessary to engender trust.

Disclosing medications error is a significant strategy to enhance standard of care because transparency builds trust (Guillod, 2013). Per Westrick and Jacob, a study revealed five strategies to improve technic in disclosing errors (2016). The five strategies are patient preparation, disclosing error in expeditious manner, promoting communication, providing support, and patient updates regarding information on investigation of error and efforts made to prevent error from recurring (Westrick and Jacob, 2016).

Strategies to prevent prescriptive errors that nurse practitioners should employ can be found in the resource library of the Institute for Safe Medication Practices (ISMP) (2016). A strategy recommended by ISMP is to include detailed instructions on medication use instead of instructions such as use as directed. Instructions such as use as directed can be misconstrued and adverse events can occur when instructions are not specific (ISMP, 2016) Another strategy recommended by ISMP is to review the list of confused drug names. Recommendations for writing prescription of drugs that are commonly confused include writing both the generic and brand name; writing the role of the drug; and in the case of electronic prescriptions, ensuring drug names that look alike do not appear in succession. Lastly, other suggestions by Woo and Robinson include writing prescriptions on prescription pad that has the name, address, telephone number, and NPI ID number; prescription contains strength, dosage, and route; avoid apothecary units of measure; avoid abbreviations; and include patient weight (2015).

Disclosing medication errors is not only beneficial not only to the provider but also to the facility. The Apology Law protects providers who are remorseful while allowing facilities to improve their processes to prevent adverse events from recurring. Strategies on techniques to improve method of disclosure as well as strategies to prevent prescriptive errors were reviewed. Lastly, it is morally and ethically imperative to disclose medication errors.