Introduction
Medical errors involving wrong drug administration are not rare, and the case of 75-year-old Charlene Murphey is not an exception. Due to the wrong treatment, the patient suffered emotional and physical distress, leading to a fatal outcome (Timms, 2022). Prosecutors claim that Murphey was intended to be given a dose of the sedative drug Versed. Yet, instead, she received an injection of the drug called vecuronium, which resulted in the patient being incapable of breathing (Timms, 2022).
Errors made by the nurse, RaDonda Vaught, were deemed criminal negligence. Based on a Tennessee Bureau of Investigation examination, she overrode the healthcare network on a computer when she was unable to locate the Versed medication (Medina, 2022). Vaught typed in “VE” and selected the first available drug on the list, which was the paralyzing vecuronium (Medina, 2022). As a result, the risks associated with such a medical error encompass emotional, physical, organizational, and financial consequences. Therefore, to prevent such issues in the future, the NPSG.03.04.01 Goal dedicated to medication labeling should be incorporated into the healthcare system, reinforced by standardizing the labeling process, preventing drug misuse, and wrong administration.
Medication Error in the Environment and Event
The medical error that led to Charlene Murphey’s death happened at the Vanderbilt University Medical Center, which could feature a chaotic, complex environment. It was concluded that a healthcare system override during the search for the prescribed medication in this particular circumstance caused a drug administration error (Medina, 2022). Vaught, the nurse, attempted to locate the drug in the system by entering its initials and selecting the first medication, which resulted in the delivery of a lethal dose of the wrong drug (Medina, 2022). As a result, environmental factors can be seen as contributors to the mistake.
On the one hand, the nurse likely selected the wrong medication because she felt rushed to find it in the stressful hospital setting. However, the worker asserted that she was distracted when the drug was administered to the patient (Medina, 2022). She is confident that her poor judgment did not trigger either the incident or the error (Medina, 2022). The mistake might, therefore, have been caused by environmental factors.
Risks Associated with the Event
The prescription failure in Charlene Murphey’s case presented several concerns, namely risks associated with one’s mental and physical health, financial matters, and organization. In general, patients may experience bodily harm as a result of pharmaceutical mistakes, which are preventable due to complications, such as allergic responses (Pozgar, 2020). As unfortunately illustrated by the death of Charlene Murphey, these mistakes can also have fatal consequences in certain instances. Thus, it is unquestionable that healthcare professionals must take measures to guarantee the safety and protection of patients.
Another type of risk associated with the wrong drug administration is the mental health implications. In such cases, in addition to physical symptoms, the patient may also experience emotional distress, such as tension and anxiety (Pozgar, 2020). These feelings can impact the patient’s overall health and well-being, leading to additional complications.
In the case of Charlene Murphey, the patient experienced distress due to cardiac arrest and suffocation (Kelman, 2019). Additionally, the immediate family was also emotionally affected by this situation. As a result, it is crucial that healthcare professionals not only mind the physical side effects of a prescription mistake but also pay close attention to any potential emotional discomfort. Consequently, this will help healthcare professionals achieve the most significant outcomes for their patients by approaching drug mistakes holistically, rather than focusing solely on physical symptoms.
In terms of financial risks, the hospital may face numerous negative consequences due to medical errors, such as incorrect medication administration. For example, any litigation resulting from the incident might lead to the healthcare institution enduring significant costs paid to the victims (Pozgar, 2020). Additionally, as a result of the oversight, they may have to pay monetary penalties to regulators (Pozgar, 2020). Furthermore, indirect expenses can be visible, including harm to the hospital’s reputation, a decline in patient and family trust, and a decline in staff morale (Pozgar, 2020). As a result, there will surely be direct and indirect liabilities, including a decrease in the demand for medical care.
Lastly, it is essential to consider the fact that any negative situation associated with the wrong drug administration will have detrimental effects on the facility’s reputation. Healthcare establishments with a history of medical errors can no longer command the trust and confidence of patients and their families, resulting in a decline in demand for hospital services (Pozgar, 2020). Aside from this, any legal liability associated with the medical error will lead to plummeting shareholders’ confidence and distort the institution’s brand image (Pozgar, 2020). As a result, to recover from the incidents, the hospital must focus on countless measures to address the issues and prevent them from happening in the future. Thus, Charlene Murphey’s case entails risks for the patient, staff, and the hospital.
NPSG Goal and Risk Analysis
Executing the new goals necessary for the transformation at the Vanderbilt University Medical Center is the next stage of problem analysis. The National Patient Safety Goals (NPSGs), developed to improve patient safety, contain crucial goals that must be implemented. The goal NPSG.03.04.01 is particularly pertinent to Charlene Murphey’s situation. According to this objective, staff must “label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings” (The Joint Commission, 2021, p.1).
This objective will help reduce the mistakes associated with incorrect drug administration and ensure that patients receive the appropriate medication and care. According to the study of Rasool and colleagues (2020), the erroneous identification of medications is a substantial risk factor in medication errors. Moreover, medical errors of this type might occur more frequently and, therefore, need consideration (Rasool et al., 2020). Therefore, medical facilities must take all necessary safety measures to protect patients.
Organizational Risks
In terms of organizational risks, the NPSG.03.04.01 goal lowers the likelihood of liability. As was discussed above, medical malpractice can result in adverse outcomes, including patient harm, litigation, and damage to the hospital’s status. The risk of a pharmaceutical error can also increase due to prolonged hospital stays, higher resource utilization, and the need for additional medications. Therefore, properly labeling medications, prescription containers, and other treatments helps reduce medication errors.
Financial Risks
Moreover, it can be seen that organizational risks are closely connected to financial risks and the incorporation of the NPSG.03.04.01 The goal is necessary. As emphasized recently, healthcare institutions can be subject to litigation due to the wrong drug administration. In this case, hospital liabilities will follow, and the institution must pay the victim for the malpractice. However, when the mentioned goal is incorporated, the likelihood of mistakes will decrease. In this case, the causal relationship can be observed since reducing risks associated with patient harm will result in low financial burdens.
Patient Emotional Risks
Furthermore, the NPSG.03.04.01 Objective: Reduce the emotional risks faced by hospital patients. When patients and their families believe their care is unsafe, emotional distress frequently results. Moreover, medication mistakes can result in unfavorable outcomes, including patient injury, which can disturb patients and their families emotionally. As seen in the case of Charlene Murphey, due to the fatal outcomes of the patient, her family had traumatic experiences. In addition, the patient was exposed to the stressful experience and pain before dying. Therefore, measures dedicated to medication and its administration are of utmost importance.
Patient Physical Risks
Finally, the given objective can be a helpful tool for reducing patient physical risks. As seen previously, medication mistakes may cause adverse outcomes, including patient injury and mortality, as in the case of Charlene Murphey. However, the risks of physical damage to the patients can decrease when hospital employees know proper medication labeling and administration.
Overall, to lower organizational, financial, emotional, and physical risks in hospitals, the NPSG.03.04.01 The goal of requiring personnel to label all medications, medication containers, and other supplies is essential. On the one hand, the given approach can help significantly reduce the likelihood of litigation and reputation damage, which are closely connected to financial burdens. However, it will contribute to better patient satisfaction and reliability. Thus, healthcare institutions should strive to accomplish this goal to provide the highest possible standard of safety and effectiveness of care.
Compliance with NPSG Goal
Labeling Medications, Containers, and Solutions
The first fundamental approach that will help comply with NPSG.03.04.01 is labeling all drugs, prescription vessels, and other substances in perioperative and administrative contexts. In this instance, marking substances used for irrigation, injection, and topical administration fall under this category. The name of the drug, its strength, dosage, administration method, and expiration date must all be listed on the packaging (Ostendorf et al., 2019). Additionally, the pharmaceutical should clearly state whether the solution is sterile. Consequently, knowing labeling patterns and methods can help minimize medical errors.
Standardize the Labeling Process
The second approach that applies to compliance with the goal is for healthcare institutions to standardize the labeling process to guarantee its accuracy and consistency. A policy outlining the specifications for identifying pharmaceuticals, medication containers, and other remedies can be created to accomplish this. As a result, all employees who handle prescriptions and treatments should be informed of the policy. Healthcare organizations can also develop a standard label template with all the required information (Ostendorf et al., 2019). As a result, this technique can assist the staff in quickly distinguishing the medications and preventing accidental drug mixing.
Provide Education and Training
Education and training are also vital to ensure staff members understand the significance of labeling medications and prescriptions. Healthcare facilities can provide instruction and education on labeling during orientation and ongoing training sessions (Ostendorf et al., 2019). The sessions can include information on the risks associated with unlabeled medications, the importance of accurate categorization, and the penalties for violating NPSG.03.04.01. This strategy will ensure that all employees know the procedure and its implications.
Use Technology
Lastly, hospitals can use technology to improve the accuracy and efficacy of labeling, including barcode scanners and electronic drug administration records (eMARs). Pharmaceutical labels can be scanned using special barcode readers to verify that the medication was requested (Ostendorf et al., 2019). Moreover, eMARs may ensure that the correct patient receives medication at the appropriate time (Ostendorf et al., 2019). Technology will be employed in this instance to enhance, optimize, and simplify the entire procedure.
Most Appropriate Action
As the organization’s primary risk manager, I have looked into numerous concerns regarding giving patients the incorrect medication. The hazards encompass the emotional, physical, financial, and organizational ranges. The next phase was to outline some actions that may be taken to reduce these risks and promote transformation. Some of these measures include standardizing the labeling process, educating staff members on medicine labeling, relying on technology for precise identification, and labeling the drug immediately. In my opinion, standardizing the labeling process would be the best course of action.
In principle, standardized labeling would make it easier for staff to identify the proper medication by ensuring that all prescriptions are labeled uniformly. Additionally, it would reduce the likelihood of mistakes brought on by labeling technique confusion (Ostendorf et al., 2019). Furthermore, it is crucial to consider this choice as it might make it easier to teach new personnel. Staff members are more likely to recall and follow a consistent labeling procedure after receiving training on how to do so (Ostendorf et al., 2019).
The tactic can lessen the number of mistakes made by employees unfamiliar with the labeling process. Additionally, it is crucial to consider the possibility of language barriers because a standardized process can make mistakes less probable (Ostendorf et al., 2019). Consistent prescription labels make it easier for staff members who speak different languages to identify the appropriate drug. This would reduce the likelihood of errors being made due to miscommunication between staff members who speak various languages.
Overall, standardizing the labeling procedure is the best course of action to reduce the dangers of giving patients the incorrect medication. Such a way would simplify the labeling process, reduce the likelihood of confusion-related mistakes, simplify onboarding new staff, and reduce the likelihood of linguistic mistakes. Incorporating the policy will help the organization guarantee that patients receive the correct prescription and reduce the dangers of giving the wrong medication, including those that are psychological, physical, organizational, and financial.
Conclusion
Hence, the healthcare system should incorporate the NPSG.03.04.01 goal devoted to medicine labeling, reinforced by standardizing the labeling procedure, limiting drug misuse, and incorrect administration to avoid such problems in the future. The NPSG. 03.04.01 aims to reduce the potential liability regarding organizational hazards. Additionally, it is clear that financial and organizational risks are intertwined, necessitating the inclusion of the NPSG.03.04.01 goal. The NPSG.03.04.01 goal also lessens the emotional dangers that hospital patients encounter.
Finally, the stated goal can be viewed as a valuable tool for lowering the physical risks to patients. Risk-reduction strategies include standardizing the labeling procedure, training staff on proper medication labeling, utilizing technology for accuracy, and labeling drugs immediately. Standardizing the labeling procedure would be the wisest action in the given case. Essentially, using standardized labeling would simplify staff efforts to identify the correct medication by guaranteeing uniform labeling across all prescriptions. It can also reduce the likelihood of mistakes brought on by misunderstandings due to the existence of various labeling systems and linguistic barriers.
References
Kelman, B. (2019). Vanderbilt death: Victim would forgive nurse who mixed up meds, son says. The Tennessean. Web.
Medina, E. (2022). Ex-Nurse convicted in fatal medication error gets probation. The New York Times. Web.
Ostendorf, W., Perry, A. G. G., & Potter, P. A. (2019). Nursing interventions & clinical skills. Elsevier Health Sciences.
Pozgar, G. D. (2020). Legal and ethical essentials of health care administration. Jones & Bartlett Learning.
Rasool, M. F., Rehman, A. U., Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Hassali, M. A., & Hayat, K. (2020). Risk factors associated with medication errors among patients suffering from chronic disorders. Frontiers in Public Health, 8, 1-7. Web.
The Joint Commission. (2021). National Patient Safety Goals. Web.
Timms, M. (2022). Murphey family releases statement as RaDonda Vaught verdict bursts into Nashville DA race. The Tennessean. Web.