Medication Errors in Nursing: Ethics of Veracity and Gate Keeping

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Part of the nursing ethics is the immediate reporting and filing of any medication error committed during the span of nurse’s duty. Standard protocol mandated by most institutions is the placement of incident report upon committing the mistake; however, practitioners do not place these records on the patient’s permanent database or even on the patient charts to avoid compromise of their medical comrades.

The main issue confronting such practice is the ethical principle of professional gate keeping versus duty of veracity and the violation of patient’s right to know every event of the care process. b. Problem Background Based from the definition of National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), medication error is considered as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer” (NCCMERP; cited in Brendle, 2007 p.

146). Nurses are confronted by medication errors often times and the act of filing an incident report to alert other members of the health care team is indeed the best collaborative intervention supported by their duty of nonmaleficence (Yeo and Moorhouse, 1996 p. 295). However, these reports are purposely undocumented in the patient charts or permanent records to prevent the risks of legal suit against the practitioner who committed the error, which arguably contradicts to the ethical principle of nurses’ duty of veracity. II. Review of Literature a. Medication Error

Medication error is a critical violation of the five rights of medication administration, which can lead to legal liabilities of malpractice or incompetence (White, 2000 p. 486). According to the reports made by the Institute of Medicine (IOM), medication errors are the most prevalent health care errors in the hospital practice affecting approximately 3. 7% of the patients (Brendle, 2007 p. 146). In case of medication errors, the nurses are obliged legally and ethically to report them directly to the nursing manager or in charge physician as mandated.

According to Josephson (2005), improper medication administration can double the risk of the patient from dying due to the complications brought by the misadministration of the drug (p. 53-54). IOM reports state that medication errors approximately cause 44,000 to 98,000 deaths annually with liability and health care costs accounting to U. S. $17 to $29 billion each year (Brendle, 2007 p. 146). b. Professional Gate Keeping: Process of Containing the Error

Part of the medical team code is to protect the credentials and status of their co-health care providers from external professional threats, which is known as professional gate keeping (Pickering and Thompson, 2001 p. 156-157). According to Timby (2008), after committing a misadministration of medication, the nurse immediately files the incident using the incident sheets or accident form to document the incident; however, this document is not made available via the patient’s permanent record or chart documentation as a form of professional gate keeping (p. 775).

Medication errors are filed using this reports to formally endorse the facts of the incident to either the physician or nursing manager. According to Roe (2002), once the incident report has been submitted, the nurse responsible for the mistake must document the interventions done (e. g. administration of antidote, etc. ), individual responsible for the counter intervention and time and date (p. 6). The incident report and the exact details of the mistake are not documented in the patient chart to protect the practitioner from legal suit (Timby, 2008 p. 775).

Even if the documentation of the incident is ethically compromised based on the principle of veracity, the health care team ensures the reversal and cure of any possible complications dealt by the misadministration of the drug. According to Williams (2008), it is always important to perform timely and accurate documentation in order to prevent the misadministration of any medication. Training nursing staffs on the different error-preventive systems have become crucial to the management of the workforce.

Capriotti has emphasized the need for periodical review and update of medication calculations as preventive tasks against medication errors. According to Davis (2008), an e-learning system was designed to facilitate individualized training and learning packages involving the controlling, storage, administration, wastage and disposal of medicines. c. Ethical Principle of Veracity Based on the principle of veracity, the nurse is also obliged to keep the patient informed on all the events associated to his or her health care regimen.

According to Boyd (2007), the ethics of veracity mandates the health care provider to tell the patient all truths concerning his or her health care process (p. 169). Despite the legal and professional risks of disclosing the mistake committed by the nurse, the ethics of veracity demands the disclosure of information to the patient and other involved members of the health care team (Bosek and Savage, 2007 p. 376). According to Lipe and Beasley (2003), the principle of veracity demands the disclosure of information either by the designated nursing head or physician involved in the patient care regimen (p. 232).

However, if the institution adheres to the ethical principle of veracity, another principle of health care professionalism –gate keeping- becomes compromised. According to Bosek and Savage (2007), the nurse must immediately report the incident to the nursing leader due to three most important rationales, specifically (a) the nursing leader has an ethical commitment to benefit the nurse staffs, (b) nursing leaders are tasked to protect the patients assigned in their corresponding department, and (c) nursing leaders require the filing of incident reports to better evaluate the performances of their nursing workforce (p. 376).

In the study of Luk, Ng and Ko et al. , K. (2008), health care authorities are likely to comfort, understand and support their staffs following the disclosure of incident, which consequently removes any existing professional barrier for gate keeping. However, the principle of veracity still disapproves the non-disclosure of error to the patient. III. Discussion In synthesis of the discussion, medication errors can cause a life threatening harm to the patient.

If the health care provider do not immediately notify or disclose the truth of the actual accident to the appropriate personnel – nursing leaders, physicians, the patient may suffer from the complications of the drug misadministration (Roe, 2002 p. 6). On the other hand, if the health care provider discloses the information to the health care authorities involved, the professional and competency evaluations of the nurse concerned may become affected (Yeo and Moorhouse, 1996 p. 295).

Nonetheless, the nurse satisfies the principle of veracity by telling the truth of the situation to the health care authorities filing, which aims at providing the best interest for the patient. However, such act fails to satisfy veracity on the part of the patient since the incident report remains undocumented on the patient chart and permanent records (Bosek and Savage, 2007 p. 376). Furthermore, the concerned practitioner does not inform the patient about the misadministration, despite the counter procedures done to alleviate the possible complications of medication error.

Lastly, if the practitioner discloses the information to both patient and health care authorities, the nurse may be able to satisfy the principle of veracity but the patient is likely to file a suit for malpractice or professional incompetence. In all the three situations presented, the best option for the nurse is to direct the accident to the higher authorities by following the standard protocol of filing an incident report.

Next, the nurse must monitor the patient for possible reactions from the drug misadministration, while ensuring the immediate administration of interventions countering any possible side effects of the drug misadministration (Roberts and Hoop, 2008 p. 104). Considering the best interests for both patient and nurse, it is more practical to keep the incident from the permanent medical records for the protection of the health care provider under gate keeping (Pickering and Thompson, 2001 p. 156-157).

Despite the professional benefit of gate keeping, non-disclosure of the information directly to the patient may erode the patient-provider trust relationships and dramatically cause an impact to the institution’s quality of care. As supported by the study of Schulmeister (2008), the safety measures (e. g. patient identification schemes, bar code scans, etc. ) aimed at preventing these errors only reduce the incidence of errors but cannot entirely eliminate medication errors. In fact, from January 2000 until December 2005, MEDMARX pharmaceuticals recorded 2,783 errors associated to barcode verification system (Schulmeister,2008).

According to MEDMARX, wrong administration of medications commonly resulted to allergic responses manifesting rashes, swelling, itching, wheezing and pulmonary distresses (Beyea and Hicks, 2003). Nonetheless, the jurisdiction of disclosure largely depends on the health care authorities and, as long as the incident has a minor impact on the patient, the disclosure of information must still follow the principle of gate keeping. Meanwhile, appropriate interventions must be done to the patient ensuring the safety and countering of drug side effects. IV. Summary In conclusion, medication errors are likely to occur within the health care setting.

An immediate action is considered vital to the prevention of any potential life threatening risk. The nurse attending to the medication needs of the patients must be well aware of the ethical principles of gate keeping and veracity in deciding the most appropriate and practical decision to perform. These principles justify the reason for filing an incident report than directly informing the patient regarding the incident. Even though veracity fails to be applied to the patient, the nurse can still immediately disclose the information to the higher authorities of the health care team preventing further the harm on the part of the patient. In the end of the conflict, it is already the jurisdiction of the provider or institution whether to conform in the principle of gate keeping or perform according to the ethical right of veracity.

References

  • Beyea, S. C. , & Hicks, R. W. (2003, September). Oops the Patient is Allergic to that Medication. Patient Safety First, 77, 650-654.
  • Bosek, M. , & Savage, T. (2007). The Ethical Component of Nursing Education: Integrating Ethics Into Clinical Experience. New York, U. S. A: Lippincott Williams & Wilkins.
  • Boyd, M. (2007). Psychiatric Nursing: Contemporary Practice. New York, U. S. A: Lippincott Williams & Wilkins. Brendle, L. (2007). Best Practices: Evidence-based Nursing Procedures. New York, U. S. A: Lippincott Williams & Wilkins.
  • Capriotti, T. (2004, February). Basic Concepts to Prevent Medication Errors. MEDSURG Nursing, 13, 21-65. Davis, C. (2008, September). A spoonful of training…. Nursing Standard, 23, 20-21.
  • Josephson, D. L. (2005). Intravenous Infusion Therapy for Nurses: Principles & Practice. London, New York: Cengage Learning. Luk, L. , Ng, W. , & Ko et al. , K. (2008, June). Nursing Management of Medication Errors. Nursing Ethics, 15, 28-39.
  • Lipe, S. K. , & Beasley, S. (2003). Critical Thinking in Nursing: A Cognitive Skills Workbook. New York, U. S. A: Lippincott Williams & Wilkins.
  • Pickering, S. , & Thompson, J. (2003). Clinical Governance and Best Value: Meeting the Modernisation Agenda. New York, U. S. A: Elsevier Health Sciences.
  • Roberts, L. , & Hoop, J. (2008). Professionalism and Ethics: Q and A Self-Study Guide for Mental Health Professionals. New York, U. S. A: American Psychiatric Pub.
  • Roe, S. (2002). Delmar’s Clinical Nursing Skills & Concepts. London, New York: Cengage Learning.
  • Schulmeister, L. (2008, June). Patient Misidentification in Oncology Care. Clinical Journal of Oncology Nursing, 12, 495-498.
  • Timby, B. (2008). Fundamental Nursing Skills and Concepts. New York, U. S. A: Lippincott Williams & Wilkins.
  • White, L. (2000). Foundations of Nursing: Caring for the Whole Person. London, New York: Cengage Learning.
  • Williams, L. (2008, June). Was the medication given?. Long-Term Living, 57, 53-55.
  • Yeo, M. , & Moorhouse, A. (1996). Concepts and Cases in Nursing Ethics. New York, U. S. A: Broadview Press.

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