"Medication Errors"

I’d like to express my gratitude to the staff on Ward G54 for their attentive and personal care as they work tirelessly to look after patients and I understand the tough job they have, especially in COVID times.

Unfortunately, there are some significant issues that have come to light, that I feel are of concern and that, in my opinion, are to the detriment of patient care, that need to be brought to attention. 

The main issue is that over my two-week admission earlier this year, I experienced several daily drug errors. Upon saying this, I was in the position to advise all nurses of the errors which were then corrected without issue.

It seemed most of the errors occurred with Graduate nurses but this was not always the case. It got to the point towards the end of my admission where I insisted on senior nurses looking after me as my anxiety levels were getting extremely high and I was exhausted. 

The errors were as follows:

> Morning 8 am oral drug/s doses is where the majority of drug errors occurred where I believe I was:

 - Given incorrect drug dose as per drug chart or not being supplied (and having to ask for them) - magnesium, salt tablets, Vitabdeck and prednisone.

- Given the incorrect Alvesco puffer 160 (should have been 80).

- Not supplied Spiriva inhaler for 5 x days after admission despite requesting daily.

On a couple of incidents, I did not receive the prednisone until after 12 pm even after requesting it several times. Prednisone affects sleep and must be taken as early as possible, thus charted for 8 am. On three occasions, I had to ask for prednisone and did not receive it until early afternoon as I had forgotten to ask. I understand that sometimes prednisone was for review but I believe doctors always did this at around 10 am.

Then on other occasions, I have had nurses (mainly graduate) wake me at 7:30 am to see if I have taken my Creon. Creon is a drug that is taken PRN, with a fatty meal to digest fats for absorption. I self administer this drug of my own accord, when necessary. I do not eat breakfast and patients do not have a breakfast tray even delivered prior to 8 am, even if I did eat breakfast. Shouldn't nurses know what the drug they are giving the patient is prescribed for, as part of the drug regime?

Another example, I was woken at 7:30 am to see if I have had a Fresubin, a high-calorie drink. Seriously, is this best practice and holistic nursing, to wake a patient that has been sleep deprived (patients with CF having sleep is extremely important) for what I feel was a non-relevant issue? I was literally only receiving 3-4 hours of sleep per night which was handed over to the morning shift staff.

As an experienced nurse myself, I believe from my observations, nurses were just rushing to get their job done and do not look at the patient holistically. When you have a chronic disease such as CF, have not been sleeping (I believe this is passed on by the night staff) for non-important medication/treatment that a patient does not need to be woken for ie. Creon and high-calorie drinks or oral medications. I understand they are under time constraints but I am sure there are other patients awake that can be attended to and the accuracy of medication dispensed, more important in my opinion.

I believe there are a few issues of six rights of basic medication administration that are not being adhered to; right patient, right drug, right dose, right time, right route, right documentation, therefore, I feel something in the medication distribution system is failing.

What concerns me is, what if I was incompetent in managing my own treatment and unable to be alert to these drugs errors. Ok, my medications are not life-threatening if given an incorrect dose or not received, but what concerns me is what if they were essential medications, causing morbidity or mortality.

Another typical example is a grad nurse (not new) coming in at 9:30 am. I had been awake since 6:30 am due to cleaner polishing the hallway floor!

1st) they took my observations,

2nd) gave me my oral medications (that I believe were incorrect) and

3rd) administer IVAbs. Clearly, IVABs being 1.5hrs late would be the priority, then my oral tablets and then observations. Again, this is where I think basic nursing supervision or support may be lacking. 

I would like to question, and am extremely curious with all the errors I have observed, do junior nurses now have enough support and training or are they being overburdened with their patient loads? Is it a generational change as I believe it is certainly not something I saw when I nursed on the wards? If we were overwhelmed, we asked for help. 

I believe health is a state of well-being and is defined as the optimal functioning of all physical, emotional, psychological and environmental well-being, not just the absence of disease or in the case of CF, being an inpatient in the hospital for often long periods of time for a chest infection exacerbation or other health-related comorbidities. 

This seems like a rather long ‘Care Opinion’ but I feel it goes without saying that all these factors are important for people with or without CF. Drug errors can be serious and the rate I have experienced them is, in my opinion, of obvious concern as it could be life-threatening. I also believe something in the chain for training/learning has broken down.

Basically, if I am picking up these errors on literally a daily basis, what is happening to other patients that do not have a good insight and control into their health?

Staff skills