Assessment 2 Topics: Medication Errors, Ethical Principles, Legislation Essay.

1. Examine the principles of quality use of medicines (QUM), as related to nursing practice 3. Analyse the professional and ethical implications of medication administration and the associated legislative requirements to nursing practice

Topic 1: Medication Errors

Instructions: Assessment 2 consists of completing 3 (three) topics with questions linked to a Coronial Clinical case summary.

Step1: Read the Coronial clinical case summary. The link to this document is available under the ‘Assessment for this Unit’ tab: Under Assessment 2. 

Step 2: Using the Coronial clinical case summary, complete the 3 topics listed below addressing the questions. You are expected to attempt all three topics.

Academic essay format is required therefore this written work requires 1 (one) introduction and 1 (one) conclusion for all three topics. 12 point font and double-line spaced.

The following format is to be used to present your essay (including topic headings): - First page: Cover page - Next page: Table of Contents - Next page:

Essay

• Introduction   

• Topic 1: Medication Errors 

• Topic 2: Ethical Principles  

• Topic 3: Legislation

• Conclusion - Last page: References

APA referencing (6th edition) is required (click this link to access the APA abridged guide or via the course Moodle site under the 'Assessment' tab). 

NB: journal articles less than 10 years old, textbooks and other sources less than 5 years old should only be used.

NB: This assessment has a minimum mark or grade – This assessment contributes to 30% of your marks overall for this unit (all three assessments combined will give the final grade). However you need to score at least 25% of overall marks for this assessment to pass the unit and satisfy the leaning outcomes regardless of obtaining pass marks in the other assessments for this unit.

There was a significant medication error that occurred that led to a poor outcome for this patient in this Coronial clinical case. 

 Briefly summarise the medication error that occurred here. - Explain how nurse A, Nurse B and Nurse C each contributed to the error which led to the poor outcome for Mr L.  • Include in your discussion at least one (1) failing of professional nursing practice or procedure that may have contributed to this medication error - Review the NSQHS Medication Safety Standard 4 item 4.6. Identify how following this action could prevent or reduce the risk of such a medication error occurring.

Ethical principles relate to medications just as they do to any other nursing practice. Therefore ethical principles apply to nurses’ practice in the administering of medication to Mr L.

After reading the Coronial clinical case summary: - Describe each of the following ethical principles: o beneficence o non-maleficence - Explain how these principles are in opposition to each other in this clinical case summary:  o Were either of these ethical principles upheld by these nurses? Yes or no. Explain your response.   NB: It is expected that you write in third person (no ‘I’ or ‘we’ statements).

Topic 2: Ethical Principles

Many laws govern medication and medication administration. The Registered Nurse has a responsibility to be aware of those that are relevant to their practice. With the clinical case summary in mind:

Discuss the significance of drug legislation to nursing and why nurses need have a responsibility to be aware of these laws. Include in your discussion the federal legislation that controls medications and how   - State the legislative schedules of fentanyl and irbesartan, medications discussed in the clinical case summary. Describe the differences in the legal requirements in storage and documentation required of these scheduled medications to Mr L. 

Coronial Clinical Case Summary: “Checks and Balances” Mr L was a 54 yr old male patient who was admitted to hospital to undergo a day surgery procedure for an anterior cruciate ligament (ACL) reconstruction to his left knee (an ACL reconstruction involves replacing the torn anterior cruciate ligament with a graft from the hamstring or patella). He was expected to be discharged home the following day. However at approximately 00:56am the next day after his surgery, despite attempts to resuscitate him, Mr L was pronounced dead. Mr L was from Hong Kong, he was in a relationship and had two children from a previous marriage. He was athletic and enjoyed skiing. Unfortunately he had a skiing accident damaging his cruciate ligament, this was further aggravated when he fell in his restaurant. On the day of his surgery Mr L was in good physical health. His only medical history was hypertension controlled with an antihypertensive medication, irbesartan.  Mr L’s surgery commenced at 1:25pm and went unremarkably well. He was then sent through to recovery for ongoing assessment. A brief handover occurred between the anaesthetist, Dr K and the recovery nurse, Nurse A, stating he will prescribe the standard medication orders for Mr L. The standard medications include oral oxycodone 510mg every 4 hours as required, regular paracetamol 1gm and an anti-inflammatory, celecoxib (Celebrex).   At 1:55pm whilst Mr L was in still in recovery Dr K commenced prescribing these medications into Mr L’s medication chart.  At the same time he also decided to write up medications for his next case. Without checking the name of the medication chart, he prescribed the standard medications for Mr L. At approximately 2:00pm Dr K was distracted by another incident in recovery and did not realise he still had Mr L’s medication chart open. He continued to prescribe a fentanyl 100mcg transdermal patch (Fentanyl patch) every three days in Mr L’s mediation chart; a medication not part of the standard medication for post-operative pain relief and is the strongest fentanyl patch available.  At the same time Nurse A was due for a break. Nurse A had not checked the medication chart prior to leaving and therefore was not aware of the additional prescribed medication. Nurse A gave only a brief verbal handover to the relieving registered nurse, Nurse B, which only consisted of a medication handover involving the standard medications which the anaesthetist had stated he was to prescribe. 

Mr L was transferred at 2:30pm to the ward for overnight observation. A brief verbal handover was attended by Nurse B to the ward nurse, Nurse C.                                          

At approximately 4:00pm Mr L complained of pain at a 7/10 level, he was given his prescribed medications which consisted of oxycodone 5mg and paracetamol 1gm by Nurse C who also helped him reposition and offered an ice pack. Nurse C saw that he was written up for a fentanyl patch. Before 5:00pm another ward nurse was asked by Nurse C to check and sign the fentanyl patch from the controlled drug cupboard. The patch was applied to Mr L’s arm and both signed the drug had been administered in the medication chart.  (NB: There was no suggestion in his records that Mr L had ever taken opioids before. Transdermal patches are also not appropriate to use for relieving ACL reconstruction postoperative acute pain.) Change of shift to night duty occurred and the junior nurse, Nurse D at 10:20pm, conducted the first set of observations of Mr L and these were found to be within normal range. At 00:20am Nurse D went back to carry out the next set of observations where it was noted Mr L’s breathing was shallow at times and appeared to be irregular. At 00:30 Nurse D informed the senior nurse of the changes to Mr L’s breathing and concerns that he was only responsive to voice and light stimuli. At this point Nurse D was instructed by the senior nurse to administer 6 litres of oxygen therapy via a face mask and the senior nurse would review when free.  When Nurse D returned to Mr L’s room he was sweaty and his breathing was continuously shallow. Nurse D attempted to rouse Mr L but there was no response and had difficulty finding a pulse. Nurse D pressed for assistance hitting the emergency button. The emergency code team arrived despite continued efforts to resuscitate, at 00:56 Mr L was pronounced dead. 

Topic 1: Medication Errors

Quality Use of Medicines (QUM) is part of the major objectives of Australia’s National Medicines Policy. This refers to the selection of option so management wisely. It also involves choosing of medicines only if it is necessary (Clark et al., 2014). Medicines should be used safely and effectively. The main objective of the National Strategy for QUM is to provide betterment of the health outcomes for all Australians and to make the best possible use of medical facilities. This paper highlights the impact of medication error on the health outcome of the patient. In addition to this, the paper illustrates the ethical principles and legislative rules that should be complied with during nursing practise.

Poor nursing practices shown by the nurses had contributed to the poor health outcome of patient Mr.L. while medication was being prescribed by Dr.K, the nurse A was absent, whereas she should have been present on the scene. Additionally the nurse A failed to check the medication char before leaving for break hence was not aware of the fact that new medications had been added to the medication chart of the patient. While the patient was handed over to nurse B, there was only a standard medication handover which consisted of medications provided by Dr.K. after some time, only a brief verbal handover was attended by Nurse B to the ward nurse, Nurse C. All these negligence summed up to the poor health outcome of the patients’ health (Kim & Bates, 2013).

The nursing practise demands care to be provided to ensure appropriate administration of medicines. All nurses have been trained with the “six rights of Nurses Administering Medications”. These includes the “right to a complete and clearly written order, the right to have the correct drug route and dose dispensed, “the right to have access to information, the right to have policies on medication administration”, “the right to administer medications safely and to identify problems in the system” and “the right to stop, think, and be vigilant when administering medications” (Melnyk et al., 2014).  In this context the right to have the access of information has not been maintained properly since the nurse had not been updated about the addition of the new medications in the chart. The nurses before administrating any drug should ask questions about the medicine, which was not observed.

The NSQHS Medication Safety Standard 4 item 4.6 states that the clinicians must review the current medication orders of the patients. This should be conducted against any past history of medication or the documented plan of treatment. The clinicians should reconcile if any discrepancies are present on the transition and presentation of care (Adhikari et al., 2014). In order to improve medication administration, steps should be taken like matching of the medicine orders that are current with the BPMH. This should be done ideally within 24 hours of admission. Suring transfer, the current list of medicine should be checked and communicated while handover especially when medicines are recharted. After discharge, the medicines that a5e ordered must be checked to make sure that they match with the prescription present on the discharge plan along with medicine list.  It should confirm the changes that has been documented (Twigg, Duffield& Evans, 2013).

Topic 2: Ethical Principles

The action that is done for the benefit of others is referred to as beneficence. Such actions are taken in order to prevent harms and help to improve the situations of others. In medical application, beneficence must be observed to refrain from causing of harm to the patients. An ideal beneficence involves acts of generosity and benefiting others. The goal of medicine as a whole is to promote the welfare of patients (Judkins-Cohn et al., 2014). This involves possession of skills by the health personnel and knowledge that help them to assist others in needful situations. The relationship is such that physicians or nurseshave an obligation to prevent harms and remove them along with weighing and balancing possible benefits which needs to be taken. Beneficence also includes protection of the rights and defending others along with rescuing individuals who are in difficulty. This might involve patients with disabilities (Adhikari et al., 2014).

Non-maleficence means not to do harm. The individuals involved in healthcare must avoid getting involved in ineffective treatment methods or practising malice towards the patients. One of the consistent ethical issue is that whether the benefits are able to outweigh the burdens (Judkins-Cohn et al., 2014). Care should be taken to ensure that the patients are not put in any risky situation where there is no possibility of benefit. Therefore the patient might have a chance of getting harmed. In addition to this, the healthcare personnel must oversee that their action has significant benefit. Most of the medications, treatment procedures and interventions might cause harm along with benefit, therefore he principle of non-maleficence should be implemented so that it provides guidelines to the care of patients.  This particular principle is of greatest helpful when it is significantly balanced against the principle of beneficence. Here in this study, non-maleficence points out that the treatment risks needs to be understood in respect to the potentiality of benefits. Finally it is the decision of the patient regarding the significant benefits, whether they are successful in outweighing the potential harms or not.

There should be a balance between beneficence and non-maleficence ethical principles. However there is always a rise of dilemma in balancing beneficence and non-maleficence principles (Parahoo, 2014). This balance is the one that is present between the risks of treatment and the benefits of treatment or taking a medical decision such as in case of conduction of a particular test or operations or administration of medication. Provision of informed consent enables the physicians to provide the information that is required to the patients. It helps the patients to make a decision regarding their treatment methods. Finally the patient is responsible for assigning weight to the factors of risks and benefits. It is required that he potential benefits of any intervention to outweigh the risks so that the action is proved to be ethical.

Topic 3: Legislation

The drug legislation provides laws that are involved in checking the safety along with the efficacy of veterinary drugs. The Veterinary Medicines Directorate (VMD) are involved in these actions. They also check and inspect the manufacturing premises of the veterinary drugs in addition to being stocked or supplied to the public (Barratt, Seear & Lancaster, 2017). It is necessary to enforce the regulations wherever necessary. It is required for the nurses to be aware of these laws so that they are not involved in any malice towards the patients. The laws provide proper guidelines for prior to administration of medication, along with during administration and after administration of the medicines. The nurses through these guidelines often receive proper training and education related to medicine administration.

Therapeutic Goods Administration (TGA) is involved in regulation of medication at the federal level. The TGA is involved in regulating the therapeutic goods by the process of pre-market assessment (Parahoo, 2014). After this there is post-market monitoring. Standards of enforcement along with licensing of the manufacturers is done by them. Additional roles involves verification of the overseas manufacturers whether they comply with the countries rules not. The organization possess obligations under the Protective Security Policy Framework. This helps to the development and documentation that is implementedto measure and to protect information from those who are unauthorised for use. They can also prevent accidental modification or release and loss of information.

Fentanyl was added to the list of schedule W drugs since its preparation contains narcotic drugs. Irbesartan falls in the category of prescription, restricted, and pharmacy-only medicine that is included in the schedule 1 of Medicines Regulations of 1984. Along with fentanyl, oxycodone is also enlisted in the list of schedule W drugs (Kumari et al., 2016).

The nurse in charge is designated to be responsible to ensure that there is presence of sufficient stocks and supplies in each wards and units for individual patients at all times. The registered manager who are in charge of the unit is ultimately accountable for medicines held, for each community team base. They ensure that Medicine policy procedures are followed correctly. They also should ensure that the security of medicines is maintained. The community staff needs to provide advice for safe storage of the medicines of the patients in safe places. Preferably it should be in a dry atmosphere or in containers (Kennedy-Hendricks et al., 2016).

Documentation is an important part of medical practise. Significant documentation provides opportunity for development of diagnostic and therapeutic plan. Proper documentation should be present in terms of the medications prescribed to the patient at every stage. In case of any change of medications, there should be recharting of the medications so that proper documentation should be present. In absence of documentation, the rates of medication errors increase as there is no prove of the medicines that are prescribed to the patient (McDonagh et al., 2014).

Conclusion

Conclusion

From the above discussion it can be concluded that the nurses should be careful with the administration of medication to the patients. There are certain guidelines that the nurses are needed to observe during their clinical practise in terms of medicine administration. The paper also highlights the beneficence and the non-maleficent ethical principles that are observes along with the need to balance between the two practices. In terms of legislation, the nurses should be aware of the drug legislations and the federal laws that govern the medication use, to prevent mal practise against the patients.

References

Adhikari, R., Tocher, J., Smith, P., Corcoran, J., & MacArthur, J. (2014). A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Nurse education today, 34(2), 185-190. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0260691713003845

Barratt, M. J., Seear, K., & Lancaster, K. (2017). A critical examination of the definition of ‘psychoactive effect’in Australian drug legislation. International Journal of Drug Policy, 40, 16-25. Retrieved from:

Clark, A., Gilbert, A., Rao, D., & Kerr, L. (2014). ‘Excuse me, do any of you ladies speak English?’Perspectives of refugee women living in South Australia: barriers to accessing primary health care and achieving the Quality Use of Medicines. Australian Journal of Primary Health, 20(1), 92-97. Retrieved from: https://www.publish.csiro.au/py/py11118

Judkins-Cohn, T. M., Kielwasser-Withrow, K., Owen, M., & Ward, J. (2014). Ethical principles of informed consent: Exploring nurses’ dual role of care provider and researcher. The Journal of Continuing Education in Nursing.Retrieved from: https://www.healio.com/nursing/journals/jcen/2014-1-45-1

Kennedy-Hendricks, A., Gielen, A., McDonald, E., McGinty, E. E., Shields, W., & Barry, C. L. (2016). Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA internal medicine, 176(7), 1027-1029. Retrieved from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2527388

Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to guidelines. Journal of Clinical Nursing, 22(3-4), 590-598. Retrieved from:https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2012.04344.x

Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Annals of internal medicine, 162(4), 301-303. Retrieved from:  https://annals.org/aim/article-abstract/2089368

Kumari, B. S., Hanuja, G. S., Nagabhushanam, M. V., Reddy, D. N., & Bonthagarala, B. (2016). Current Regulatory Requirements for Registration of Medicines, Compilation and Submission of Dossier in Australian Therapeutic goods Administration. International Journal of Advanced Scientific and Technical Research, ISSN, 2249-9954.Retrieved from:https://rspublication.com/ijst/2016/dec16/15

McDonagh, J. E., Shaw, K. L., Stephenson, R., & Gray, N. J. (2014). Are they ready and do we know they are ready? Documentation of medicine management tasks in an adolescent rheumatology clinic. Rheumatology, 53(suppl_3), iii10-iii10. Retrieved from:https://academic.oup.com/rheumatology/articleabstract/53/suppl_3/iii10/181424

Melnyk, B. M., Gallagher?Ford, L., Long, L. E., & Fineout?Overholt, E. (2014). The establishment of evidence?based practice competencies for practicing registered nurses and advanced practice nurses in real?world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence?Based Nursing, 11(1), 5-15.Retrieved from:https://sigmapubs.onlinelibrary.wiley.com/doi/abs/10.1111/wvn.12021

Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International Higher Education. Retrieved from:https://books.google.

Twigg, D. E., Duffield, C., & Evans, G. (2013). The critical role of nurses to the successful implementation of the National Safety and Quality Health Service Standards. Australian Health Review, 37(4), 541-546. Retrieved from:https://www.publish.csiro.au/ah/ah12013