title: Understanding medication errors: discussion of a case involving a urinary catheter implicated in a wrong route error.
abstract: Medication errors represent a failure in the medication use process leading to an increase in morbidity and mortality. In an effort to standardize reporting, evaluating, and trending of medication errors, the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) developed and maintains a medication error taxonomy. A case study involving a medication intended for administration via rectal tube and inadvertently given through a Foley catheter is discussed using the NCC MERP medication error taxonomy and critiqued using recent national findings. Awareness of national trends for patient safety, including emerging changes leading to best practices, updates to National Patient Safety Goals, and changes in national policy, can reduce the risk of error involvement.
authors.affiliation: Texas Tech University Health Sciences Center, School of Nursing, Lubbock, TX, USA.
authors.forename: Rodney W
authors.initials: RW
authors.lastname: Hicks
authors.forename: Shawn Coniff
authors.initials: SC
authors.lastname: Becker
authors.forename: Dorothy Greene
authors.initials: DG
authors.lastname: Jackson
mesh_terms: D000285:Administration, Rectal; D019985:Benchmarking; D002411:Cation Exchange Resins / Q000008:administration & dosage / Q000009:adverse effects; D015984:Causality; D003556:Cystitis / Q000139:chemically induced; D005260:Female; D006040:Goals; D006801:Humans; D006947:Hyperkalemia / Q000188:drug therapy; D008508:Medication Errors / Q000145:classification / Q000379:methods / Q000451:nursing / Q000517:prevention & control; D008875:Middle Aged; D015969:National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division; D024802:Nurse's Role; D010043:Outcome and Process Assessment, Health Care; D011137:Polystyrenes / Q000008:administration & dosage / Q000009:adverse effects; D012308:Risk Management; D017751:Safety Management / Q000458:organization & administration*; D014481:United States; D014546:Urinary Catheterization
chemical_list: D002411:Cation Exchange Resins; D011137:Polystyrenes; C003321:polystyrene sulfonic acid