2.50
Hdl Handle:
http://hdl.handle.net/10755/163465
Category:
Abstract
Type:
Presentation
Title:
Consequences of fatal medication errors for health care providers
Author(s):
Serembus, Joanne; Wolf, Zane Robinson; Youngblood, Nancy
Author Details:
Joanne Serembus, Assistant Professor, LaSalle University, School of Nursing, Philadelphia, Pennsylvania, USA, email: serembus@lasalle.edu; Zane Robinson Wolf; Nancyh Youngblood
Abstract:
Purpose: To describe the consequences of making a fatal medication error for health care providers. It was proposed that new knowledge gained could be used to sensitize nurses to the impact of such a damaging event on the health care provider and to assist them in appreciating the fear and guilt associated with reporting such errors. Research Question: What are the consequences for health care providers that have committed fatal medication errors? Theoretical Framework: The theory about mistakes at work by Hughes. Design: A secondary analysis, case study design was used. Data were analyzed from a descriptive study (Wolf, Serembus, Smetzer, Cohen, & Cohen, 2000) using a sub-sample of 11 respondents involved in medication errors in which death was the outcome. Sample: Eleven cases, in which patient deaths were reported, were selected from a systematic random sample of health care professionals (n=402) of nurses (n=208), pharmacists (n=112), and physicians (n=82) that was generated from a target population. Target population was obtained from a complete list of licensed professional nurses (N=161,387), physicians (N=30,111), and pharmacists (N=12,582) provided by the State Boards of Medicine, Nursing, and Pharmacy of the Bureau of Professional Affairs of the Commonwealth of Pennsylvania. Method: A self-report survey, Section I of which uses open-ended questions to elicit a description of the most serious drug error made by respondents. It includes a checklist of interventions performed as a result of the drug error. Additionally, the National Coordinating Council's Medication Error Index (Hartwig, Denger, & Schneider, 1991) was employed to determine the harm ranking of the error. A nine-point scale ranging from "0=No Error, Circumstances or events that have the capacity to cause error" to "8=Error, Death, An error occurred that resulted in patient death" evoked respondents' judgments. Section I also contains a checklist of people involved in and notified of the error. Section II addressed health care providers' responses to and concerns about the medication error. Surveys were mailed to health care providers. Respondents self administered the instrument and a demographic profile. Data collection continued for three months. Following the primary study, the investigators culled from the set 11 surveys in which respondents reported the death of a patient from a medication error. Data Analysis: Descriptive statistics were calculated using SPSS-PC. Descriptive statistics for close-ended items were reviewed for themes. The investigators also searched for latent and manifest meanings of the experience for respondents in the answers to open-ended questions, seeking to discover essential themes. Results and Conclusions: The details of the medication error were engraved indelibly in the memory of the respondents and easily recalled. For the respondents, the highest ranked responses after making the medication error were: wished to make amends, immobilized, nervous, fearful, insomnia, denial, cried, lost confidence. Highest ranked concerns were: fear for patient, fear of license suspension, judged as incompetent by coworkers, loss of respect by coworkers, fear of rejection, fear of disciplinary action. Two subjects were fired and never worked again in the agency in which the error took place. The experiential consequences of making fatal medication errors revealed essential themes. These included being responsible for a patient's death, noting failure, fearing punishment, hoping to correct the wrong, denying personal culpability, feeling guilty and depressed about the death, discerning public humiliation, needing support, coping with the error, and being fatalistic and feeling threatened about the likelihood of future errors. Nursing Implications: Blame is often cast on individuals as a result of medication errors. It is recommended that an approach to reducing medication errors in which blame is not placed on an individual but on the system where mistakes occur should take place.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2002
Conference Name:
14th Annual Scientific Sessions
Conference Host:
Eastern Nursing Research Society
Conference Location:
University Park, Pennsylvania, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleConsequences of fatal medication errors for health care providersen_GB
dc.contributor.authorSerembus, Joanneen_US
dc.contributor.authorWolf, Zane Robinsonen_US
dc.contributor.authorYoungblood, Nancyen_US
dc.author.detailsJoanne Serembus, Assistant Professor, LaSalle University, School of Nursing, Philadelphia, Pennsylvania, USA, email: serembus@lasalle.edu; Zane Robinson Wolf; Nancyh Youngblooden_US
dc.identifier.urihttp://hdl.handle.net/10755/163465-
dc.description.abstractPurpose: To describe the consequences of making a fatal medication error for health care providers. It was proposed that new knowledge gained could be used to sensitize nurses to the impact of such a damaging event on the health care provider and to assist them in appreciating the fear and guilt associated with reporting such errors. Research Question: What are the consequences for health care providers that have committed fatal medication errors? Theoretical Framework: The theory about mistakes at work by Hughes. Design: A secondary analysis, case study design was used. Data were analyzed from a descriptive study (Wolf, Serembus, Smetzer, Cohen, & Cohen, 2000) using a sub-sample of 11 respondents involved in medication errors in which death was the outcome. Sample: Eleven cases, in which patient deaths were reported, were selected from a systematic random sample of health care professionals (n=402) of nurses (n=208), pharmacists (n=112), and physicians (n=82) that was generated from a target population. Target population was obtained from a complete list of licensed professional nurses (N=161,387), physicians (N=30,111), and pharmacists (N=12,582) provided by the State Boards of Medicine, Nursing, and Pharmacy of the Bureau of Professional Affairs of the Commonwealth of Pennsylvania. Method: A self-report survey, Section I of which uses open-ended questions to elicit a description of the most serious drug error made by respondents. It includes a checklist of interventions performed as a result of the drug error. Additionally, the National Coordinating Council's Medication Error Index (Hartwig, Denger, & Schneider, 1991) was employed to determine the harm ranking of the error. A nine-point scale ranging from "0=No Error, Circumstances or events that have the capacity to cause error" to "8=Error, Death, An error occurred that resulted in patient death" evoked respondents' judgments. Section I also contains a checklist of people involved in and notified of the error. Section II addressed health care providers' responses to and concerns about the medication error. Surveys were mailed to health care providers. Respondents self administered the instrument and a demographic profile. Data collection continued for three months. Following the primary study, the investigators culled from the set 11 surveys in which respondents reported the death of a patient from a medication error. Data Analysis: Descriptive statistics were calculated using SPSS-PC. Descriptive statistics for close-ended items were reviewed for themes. The investigators also searched for latent and manifest meanings of the experience for respondents in the answers to open-ended questions, seeking to discover essential themes. Results and Conclusions: The details of the medication error were engraved indelibly in the memory of the respondents and easily recalled. For the respondents, the highest ranked responses after making the medication error were: wished to make amends, immobilized, nervous, fearful, insomnia, denial, cried, lost confidence. Highest ranked concerns were: fear for patient, fear of license suspension, judged as incompetent by coworkers, loss of respect by coworkers, fear of rejection, fear of disciplinary action. Two subjects were fired and never worked again in the agency in which the error took place. The experiential consequences of making fatal medication errors revealed essential themes. These included being responsible for a patient's death, noting failure, fearing punishment, hoping to correct the wrong, denying personal culpability, feeling guilty and depressed about the death, discerning public humiliation, needing support, coping with the error, and being fatalistic and feeling threatened about the likelihood of future errors. Nursing Implications: Blame is often cast on individuals as a result of medication errors. It is recommended that an approach to reducing medication errors in which blame is not placed on an individual but on the system where mistakes occur should take place.en_GB
dc.date.available2011-10-27T11:08:04Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:08:04Z-
dc.conference.date2002en_US
dc.conference.name14th Annual Scientific Sessionsen_US
dc.conference.hostEastern Nursing Research Societyen_US
dc.conference.locationUniversity Park, Pennsylvania, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.-
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