Quality Use of Medicines

Q1. Assess Mr Hunter's medication chart. With consideration to the casescenario, identify and explain two (2) significant risks that may be associated with the use of these medicines. (Approximately 500 words)

Ans :On basis of the Mr. Hunter’s medication chart panadol and warfarin are the drugs which can be discussed further .

Panadol is brand name of drug paracetamol. It is non steroidal anti-inflammatory drug which act as both analgesic and antipyretic. It is derivative of Para-aminophenol and under Nonselective COX Inhibitors classification (Johnson, Jung, Brown, Weaver & Richards, 2014). Acetaminophen is the alternate name of paractemol.

Adverse Effects of Pandol Are:

NAUSEA,VOMITING,ANOREXIA

HEPATOTOXICITY DUE TO INCREASED SERUM TRANSAMINASE ENZYMES

JAUNDICE

LIVER TENDERNESS

PROLONGED PROTHROMBIN TIME

LIVER FAILURE

NEPHROTOXICITY

ALLERGIC REACTIONS

Two significant risks are:

Hepatotoxicity :

When panadol is taken in mild amount ,it converts into N-acetyl benzoquinone which is high reactive intermediate.It further detoxify and conjugate with glutathione.While taking panadol in high concentration ,it will destroy the glutothione in liver and the metabolite combine with sulphydryl group in the liver cause hepatic necrosis .Various manifestations can be seen like jaundice, liver tenderness. Hepatic lesions can be reversed if treated properly. As Mr. Hunter has taken Nurofen which is Ibuprofen(NSAIDs) .Both panadol and nurofen cause the hepatic damage. .Both panadol and nurofen cause the hepatic damage if taken more than prescribed dosage. Overdosage of panadol leads to damage to liver in four stages. Four stages are:

Stages Effects

STAGE 1-PRECLINICAL NAUSEA,VOMITING,PAIN IN ABDOMINAL REGION

STAGE 2-HEPATOTOXICITY PAIN IN THE UPPER RIGHT QUADRANT,RAISE 

LEVEL OF AST &ALT ,BILIRUBIN

STAGE 3-HEAPTIC FAILURE WITH ENCEPHALOPATHY VOMITING,JAUNDICE,

GI IRRITATION,LACTIC ACIDOSIS

STAGE 4-DEATH MULTIORGAN FAILURE,COMA

 . In stage 2 hepatic damage occurs which is presented by tenderness in upper quadrant and also there is increased levels of enzymes like AST &ALT, Bilirubin in liver function tests. In stage 3 Hepatic failure can occur and there is wide abnormality in Serum transaminases, Bilirubin, prolonged PT &INR. Jaundice , Vomiting, GI irritation, Hypoglycemia, Coagulopathy ,Metabolic acidosis are signs and symptoms in stage 3.If stage 3 is not resolved or controlled it leads to multi organ failure which ultimately causes death

Nephrotoxicity:

When panadol is taken, it converts into N-ACETYL-PARA-AMINO-BENZO-QUINONEIMINE which binds to S3 segment of proximal tubule and impair its function causing renal tubular cell death .By this process cytokines increases which activate the inflammatory process and causes renal impairment.

Warfarin is a drug that reduces the blood coagulation. It is slow acting drug which is taken orally. It acts by interrupting the formation of clotting factors which are vitamin K dependent and present in hepatic system. It blocks the gamma carboxylation which is important for coagulation of blood.

HAEMORRHAGE

GASTROINTESTINAL DISTURBANCE like diarrhea

ANAPHYLACTIC REACTIONS like rash, Teratogenicity

Two significant risks are:

Haemorrhage:

It is main risk while taking this medication. Bleeding in intestinal area and cerebrovascular area are the main complication. Nose bleeding and bleeding in gums are common. It is due to blockage of gamma carboxylation of glutamate in factors VII, IX, X which are majorly responsible for coagulation.

As Mr. Hunter is having past medical history of severe hypertension. Warfarin is contraindicated in such cases. Because warfarin leads to calcification of arteries by decreases the activity of GLA protein .It further cause more systolic blood pressure and pulse pressure which happens in case of Mr. Hunter. Pulse pressure was 94 bpm on examination. In such cases we can take warfarin as a contraindication (Gorgich, Barfroshan, Ghoreishi & Yaghoobi, 2015).

 Q2. With consideration to the case scenario, describe the strategies a nurse may implement to prevent/manage the risks identified in Question 1. (Approximately 500 words)

Ans: Stratergies a Nurse May Implement to Manage or Prevent the Risk While Giving Panadol:

History taking

By taking proper history taking of any allergic reaction to panadol and any medical history of hepatic disease it can be prevented.

Observe the skin colour and lesions 

 Take blood sample to assess the liver fuction

 test ,renal function test and CBC.

INTERVENTION

Right dosage of medication can prevent the risk if given to patient as prescribed by the doctor .

Don’t use multiple preparations containing panadol. It will leads to hepatic damage if overdosage occurs.

If overdosage leads to poisoning then stomach wash is advised by using antidote N-acetylcysteine. It destruct the glutathione in liver and prevents the binding of toxic molecules to the cell constituents.

Activated charcoal is another option to reduce the absoption of panadol.

Observe any anaphylactic reaction while giving panadol and if any allergy occurs discontinue the drug.

Monitor serum level and vital signs frequently.

To reduce the stomach irritation give drug with food. It lessen the irritation.

PATIENT EDUCATION

Don’t give panadol to patient for more than 10 days as it leads to severe damage to the body

Councel the patient to assess the blood examination frequently and report if he feel any discomfort.

Strategies a Nurse May Implement to Manage or Prevent the Risk While Giving Warfarin

HISTORY TAKING

Take proper history of any allergy to warfarin

Take medical history of hemorrhagic disease,hepatic disease,renal disease,severe hypertension.

Observe the skin lesions,blood pressure.

Take a blood sample to evaluate the Liver function tests (Marcus, 2014), renal function test ,CBC, Prothrombin time.

INTERVENTION

Monitor prothrombin(PR) ratio and INR frequently to adjust the drug dosage.

Avoid intra muscular injections . Administer the drug in IV form. Once the patient is stabilize return to oral form. Intramuscular injections cause hematomas in patients who undergo coagulation therapy. 

Avoid NSAIDs along with this drug because it increases the risk of bleeding

Observe any signs of petechiae , bruises, dark coloured stool and urine as it is indication of blood loss.

In case of overdosage, administered vitamin K. It acts as antidote to warfarin. In case of emergency, fresh whole blood is required to counter the adverse effects by coagulant. IV administration of vitamin K is not advised as it has slow onset of action.

To check the drug effects, take blood samples frequently.

PATIENT EDUCATION

Counsel the patient to examine blood test frequently. It will help to assess the effects of drug.

Tell the patient about adverse effects such as Stomach bloating, cramps, loss of hair

Tell the patient to avoid the events in which he could be injured

Tell patient to avoid alcohol as it leads hepatic damage and more bleeding time.

 Q3. Apart from the rights of medication administration (right patient, right dose, right time, etc) explain three (3) strategies a nurse can implement to reduce the risk of medication errors. This should be supported by relevant literature and

Ans –Strategies a nurse can implement to reduce the risk of medication errors: Apart from the5 rights of medication administration which are correct medication given to correct patient ,correct dosage, using the correct route, and lastly it is given at correct time , some more strategies are important so as to avoid medication errors.

  • Fatigue management and Fatigue mitigation: Fatigue is an important factor when considering the administration of medications in order to reduce medication errors. As per scientific terms fatigue is an overwhelming feeling of tiredness along with sleep deprivation (Chakravarty, 2014) and less amount of energy to sustain body’s metabolic processes. This feeling of uneasiness and exhaustion can lead to impairment of various cognitive and behavioral functioning of an individual. In nursing profession this is very common as extra shifts and late night duties hamper the sleeping patterns (Bilimoria et al., 2016) and also body starts feeling fatigue and low in energy which ultimately affects their daily job activities. This badly affects the patient medication and required dosage patterns and can prove to be fatal for the patient. Sometimes the nurses administer the right drug but in an incorrect way and passage i.e. use off intravenous drug injection instead of the prescribed oral medication which can have severe drug adverse effects on the patient health. So fatigue mitigation strategies should be made an important part of the nurse regime in order to avoid medication errors. These include management of risk factors associated with fatigue. Evident studies for fatigue analysis have been reported by Pennsylvania Patient Safety Authority’s Pennsylvania Patient Safety Reporting System (PA-PSRS) which helped in providing issues that compromise patient health and medication safety issues. So fatigue mitigation along with fatigue management has to b inculcated into the daily regime of practicing registered nurses. So certain hours of service should be fixed by the medical association so that nurses donot feel fatigue due to hampered sleeping patterns and less sleep issues donot escalate further medication errors. Also nurses themselves should not let fatigue hamper their hours of service and immediately report when any such issue is faced that can compromise patient safety and health and practice fatigue mitigation strategies to avoid any medication errors.
  • Donot disturb gears :Secondly medication errors occur due to disturbance while administering and verifying the dosage, any disturbance by colleagues and seniors can lead to wrong dosage and have severe effects on patient due to medication errors. So to reduce such incidence of interruptions while administering medications, it should be mandatory for a nurse to wear a vest with proper signage (Ozturk et al., 2019) that depicts do not lanyard so as to be identified as do not disturb as she is administering medication . Also these signage will help in correct dosage and no disturbance making time to recheck on medications and patient pharmacy records. Also as per the guidelines of National Health Service, it is recommended to follow certain guidelines of prohibition on disturbance to nursing staff when they are on a three tier duty check for medication administration and dressed in fluorescent vests that clearly show donot disturb signage. Usually the registered nurses wear red tabard when they are on drug administration round (Wong, Flynn-Evans & Ruskin, 2018) so as to avoid any interruption while drug checking and administration after proper verification with the patient records.
  • Patient education and locking previous medications:The last important strategy that can help in reducing medication error is removal of patient’s old medication after admission to hospital and locking that medication so that it is out of patient’s reach. This step is very important along with proper education to patient about the potential side effects of the previous medication and why he cannot continue to take up that medication along with present treatment due to overdose which might even prove fatal or lead to further complications. Also as per the report of The Institute of Medicine (IOM) medication errors can be prevented to avoid any adverse drug reaction (Stevens, Levi & Sands, 2019) on the patient. So educating the patient will help in reducing medication errors and thus adverse drug reactions to a significant level by determining patient’s medical literacy and then guiding them in a particular way so that they understand the impact and importance of introducing new medication to avoid any errors.

References for Compromised Healthcare Worker Safety

Chakravarty, M. (2014). Compromised healthcare worker safety – Do we care?. Journal Of Patient Safety & Infection Control2(1), 7. doi: 10.1016/j.jpsic.2014.05.004

Ozturk, M., Ipekci, A., Kiyak, S. K., Akdeniz, Y. S., Aydin, Y., Ikizceli, I., & Sogut, O. (2019). Bleeding Complications in Warfarin-Treated Patients Admitted to the Emergency Department. Journal of clinical medicine research11(2), 106–113. https://doi.org/10.14740/jocmr3669

Stevens, J., Levi, R., & Sands, K. (2019). Changing the Patient Safety Paradigm. Journal Of Patient Safety15(4), 288-289. doi: 10.1097/pts.0000000000000394

Johnson, A., Jung, L., Brown, K., Weaver, M., & Richards, K. (2014). Sleep Deprivation and Error in Nurses who Work the Night Shift. JONA: The Journal Of Nursing Administration44(1), 17-22. doi: 10.1097/nna.0000000000000016

Wong, L., Flynn-Evans, E., & Ruskin, K. (2018). Fatigue Risk Management. Anesthesia & Analgesia126(4), 1340-1348. doi: 10.1213/ane.0000000000002548

Bilimoria, K., Chung, J., Hedges, L., Dahlke, A., Love, R., & Cohen, M. et al. (2016). National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New England Journal Of Medicine374(8), 713-727. doi: 10.1056/nejmoa1515724.

Yoon, E., Babar, A., Choudhary, M., Kutner, M., & Pyrsopoulos, N. (2016). Acetaminophen-Induced Hepatotoxicity: a Comprehensive Update. Journal of clinical and translational hepatology4(2), 131–142. https://doi.org/10.14218/JCTH.2015.00052

Acetaminophen-Induced Hepatotoxicity: a Comprehensive Update. (2016). Journal Of Clinical And Translational Hepatology4(2). doi: 10.14218/jcth.2015.00052

Marcus C. (2014). Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health psychology and behavioral medicine2(1), 482–495. https://doi.org/10.1080/21642850.2014.900450

Gorgich, E. A., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint. Global journal of health science8(8), 54448. https://doi.org/10.5539/gjhs.v8n8p220

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