Understanding Medication Errors One Way To Help Improve Quality Of Care

Main Category: Litigation / Medical Malpractice
Article Date: 07 Jan 2009 - 3:00 PDT

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Urologic nurses must possess a basic understanding of how to analyze and report medication errors. In the December 2008 issue of Urologic Nursing, Rodney W. Hicks, Shawn Coniff Becker and Dorothy Greene Jackson discuss tools available for evaluating and reporting medication errors.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Taxonomy of Medication Errors, a comprehensive tool for evaluating medication errors, and several national medication error reporting programs are used to understand why and how medication errors occur, report Hicks and co-authors.

Using the NCC MERP medication error taxonomy, the authors discuss and critique a case involving a registered nurse caring for a 56-year-old female patient. The nurse inadvertently administered medication through a urinary (Foley) catheter instead of a rectal tube. The patient developed cystitis and required a urologic consult to determine treatment options. While the patient experienced only temporary harm, a medication error still occurred and was reported.

Hicks and co-authors note the case raises several important points in today's patient safety environment. In this case, practice standards for safe medication use failed and resulted in the error. The authors say reviewing all steps in the medication use process prior to administering medication would protect patients.

The authors believe that rather than placing blame solely on the individual, organizational leaders should modify system-related issues that ensure this specific error does not happen again and also prevent future errors. In addition, with growing recognition of medical tubing problems that contribute to errors, the authors say labeling the urinary and rectal tubes may have presented a visual cue and prevented the error.

Hicks and co-authors suggest urologic nurses can contribute to improving the quality of care by reporting all adverse events and following national patient safety standards.

(Understanding Medication Errors: Discussion of a Case Involving a Urinary Catheter Implicated in a Wrong Route Error; Rodney W. Hicks, PhD, RN, FNP-BC, FAANP; Shawn Coniff Becker, MS, RN; Dorothy Greene Jackson, PhD, MSN, RN, NP-C; Urologic Nursing; December 2008; http://www.suna.org)

About SUNA

The Society of Urologic Nurses and Associates is a national, non-profit professional membership association with over 3,000 members and annual revenues of $1.5 million. SUNA derives its income from membership dues (only $60), conference registration fees, exhibits, advertising, grants, and the sale of educational products.

SUNA publishes a professional, peer-reviewed bi-monthly journal (Urologic Nursing Journal) and a bi-monthly newsletter (Uro-Gram). SUNA establishes the scope and standards of urologic nursing practice and the scope and standards of advanced urologic nursing practice. SUNA provides scholarships, grants and awards to deserving nurses and other health care professionals.

SUNA supports and promotes the certification of urologic nurses and associates by providing educational preparation for the examinations offered which lead to certification in three areas.

SUNA provides a variety of opportunities for participation including local chapters, task forces and Special Interest Groups (SIGS) in five major subspecialty areas.

Society of Urologic Nurses and Associates