25, 26 Errors are more likely to occur when tasks are carried out after hours by busy, distracted staff, often in relation to unfamiliar patients. Medication errors are a very real and frightening event in health care, and they deserve the concern associated with them. Registered Nurses (RNs) are particularly exposed to the risk of making medication errors since they are involved in the whole medication process and are usually the last link to the patient [1,2]. Medication errors are a very real and frightening event in health care, and they deserve the concern associated with them.  |  J Nurs Law. Medication Errors and Their Relationship with Care Complexity and Work Dynamics. Failure to perform a post-operative assessment, failure to accurately document anesthesia complications in a medical record, and failure to complete a proper informed consent. Unintentional administration of insulin instead of influenza vaccine4. In fact, medication errors most commonly reduced by the use of ADCs include missed doses, wrong patient, wrong drug, and wrong administration time. Nurses are able to identify medication errors, but are reluctant to report them. The most common types of reported errors were wrong dosage and infusion rate. 2019 Oct 10;7(21):3579-3583. doi: 10.3889/oamjms.2019.722. Sabzi Z, Mohammadi R, Talebi R, Roshandel GR. has shown that the rate of medication errors by nurses and nursing students is high, however, the report of these errors by them is low (Blegen & Vaughn, 2004; Bennerm & Sheets, 2002; Kawamura, 2001). The allegations against the intensive care unit nurse included alleged failure to properly administer the medications as ordered by the physician and failure to notify the attending physician of significant changes in the patient’s vital signs and laboratory results. Some scientific evidence on medication errors exists, including the causes of such errors and approaches to improving medication safety, but the field of patient safety research is relatively new. The most prevalent types of medication errors were related to infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%). Research has revealed that distractions contribute to medication errors. She recalled administering the potassium and believed she had advised the physician when necessary. Nurses relate the contributing factors involved in medication errors. The admitting nurse altered the patient’s medical record after the fact. By Aida Van Herk, RN, JD, Risk Management AMN Healthcare. Medication errors do occur but most can be avoided by applying the above principles. Conclusion: 3 Oshikoya et al. Nurse Educ Today. It is so unfortunate that these errors have become a part of our lives. Similar to Gladstone's study, Osborne, Blais, and Hayes's study (5) of 57 medical-surgical nurses revealed that nurses do not report medication errors 9 Increased patient workloads may predispose nurses to take shortcuts and fail to follow drug administration procedures, such as verifying patient identification. There are numerous measures in place now to cut down on errors… The on-call emergency physician attempted to resuscitate, but was unable to obtain a heartbeat and the patient was pronounced dead. Two days later and despite the potassium added to her intravenous fluids, the patient’s potassium level was noted to be 3.0 and the attending physician ordered 80 mEq of potassium to be administered by mouth. Jack Startz Hooked Patients On Drugs And Destroyed Their Faces. Table 2: Types of medication administration errors experienced by the nurses (N=250). The failure of nurses to properly follow medical procedures can result in lawsuits, loss of your license, and, worst of all, injury to patients. Improving patient safety with technology. Surgery on Wrong Side of Head. Over the past 3 days, she had been experiencing crampy left lower This cross-sectional study was conducted in 2009. There are approximately 80,000 medication errors per year that involve nurses giving medications to patients. eCollection 2019 Jul. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Frequency distribution of nursing medication…, Frequency distribution of nursing medication errors, NLM NIH rate of medication errors in nursing students was reported 48.5% and the most common type of medication errors was forgetting drug prescription (McCarthy & Kelly, … The following medication errors have happened to some people. Khalil H, Bell B, Chambers H, Sheikh A, Avery AJ. #Opiates Always double-check the label. 2004;19:385–92. Communication breakdownsare the most common causes of medical errors. Studies of ADC-related errors report on diverse patient populations with various control factors and assessment parameters. To many, celebrities undergoing … 3 161 Table 1. The major factors contributing to errors were found to be increased workload … Nursing students' perceptions of clinical learning opportunities and competence in administration of oral medication in the Western Cape. Nurses and pharmacists are responsible for medication errors involving administration (26% to 34%), dispensing (14%), and transcription (11%). 24 Among doctors depression and exhaustion are important. There were no statistically significant relationships between medication errors and years of working experience, age, and working shifts. Other telemetry unit staff indicated that the telemetry unit was in an overflow situation when the patient was transferred and the central monitoring station was not functioning. Discussion Warfarin remains one of the most frequently prescribed medications in the United States, and it appears on the Institute for Safe Medication Practices list of high-alert medications because overanticoagulation or underanticoagulation has important consequences. Unfortunately, errors can result in serious consequences for patients and legal repercussions for nurses. Despite her limited clinical skills, she believed she followed the physician’s orders appropriately and documented her actions thoroughly. 42(2) http:⁄⁄dar.ju.edu.jo⁄jmj A mean for the reported frequencies was calculated to report the rate of medication errors.45 Across hospitals and between ICUs and Nursing errors commonly revolve around … Medication errors have been a key target for improving safety since Bates and colleagues' classic reports in the 1990s describing the frequency of adverse drug events (ADEs) and the relationship between medication errors and ADEs in hospitalized patients. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. An urban medical system's exploratory study of medication errors. Medication Errors Among Nurses in Intensive Care Unites (ICU) J Mazandaran Univ Med Sci. Medication errors may occur at any point in the health care system. surveyed pediatric nurses working in a public hospital to examine their experience with medication administration errors. COVID-19 is an emerging, rapidly evolving situation. The intensive care unit nurse failed to notify the physician that the patient’s heart rate was continuing to rise. Note: There were multiple co-defendants in this claim who are not discussed in this scenario. She carried out a physician’s order which read, “Give 3.0 cc lanoxin today for one dose only”. Please enable it to take advantage of the complete set of features! If it says "ophthalmic," it's for the eyes. This case study involves a nurse working in an intensive care unit. Recent technological advances have focused on A 55-year old female was transported to the floor after recovering from a surgical procedure. Legal Expenses: Greater than $6,000 Since most cases of medication errors are not reported by nurses, nursing managers must demonstrate positive responses to nurses who report medication errors in order to improve patient safety. Cochrane Database Syst Rev. Eur J Hosp Pharm. Curationis. medication errors among registered nurses, the type and causes of these errors and the impact that administration of medications has on the professional practice of registered nurses. This site needs JavaScript to work properly. Instead, her condition deteriorated and she developed both shortness of breath and a cough. Affiliation 1 Frances Payne Bolton School of Nursing, Case Western Reserve University, OH … Her worsening symptoms motivated her to seek care a local emergency room. Many of these mistakes are avoidable if policies of the hospital governing medication administrations Disclaimer: This work has been submitted by … National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. doi: 10.1136/ejhpharm-2017-001221. Wrong site surgery is what is called a “never event” in medicine … Mater Sociomed. Al Madfai F, Zaidi STR, Ming LC, Wanandy T, Patel RP. USA.gov. The intensive care unit nurse indicated to her attorney that she believed she did not possess the clinical skills to work in the intensive care unit but there is no information as to whether she requested a change in assignment, a mentor or close supervision by a trained intensive care nurse. MEDSURG Nursing—May/June 2010—Vol. The physician ordered 30mEq of potassium to be added to each bag of the patient’s intravenous fluid, infused at 80 milliliters per hour. However, a significant relationship was found between errors in intravenous injections and gender. When the physician saw the patient that day, he noted that the patient’s white blood cell and platelet counts remained higher than normal but were dropping. Likewise, errors in oral administration were significantly related with number of patients. Medication errors may occur at any point in the health care system. This medication error took the life of an Air Force … student nurses. 2004;73:543–6. The nurse who was passing medications noted the line for Lasix had been yellowed out, which she interpreted to mean the medication was discontinued. If you do 19 There is a particular … Concepts taught in the case study include the use of conversion factors in clinical calculations; inter-conversion of temperatures in Fahrenheit and Celsius scale; construction and interpretation of graphs; the etiology, manifestation, diagnosis and treatment of pneumonia; and the medication administration system and the role that nurses can play in preventing medication overdose. Dr. David C. Ring:This 65-year-old woman with a trigger finger that did not respond to glucocorticoid injection elected operative treatment under local anesthesia. Large studies have found that the majority of ADEs—49% to 56%—originate when physicians prescribe or order medications. In addition, her vital signs were within normal range and she was not in respiratory distress. Don't make these same mistakes: Confusing eardrops and eyedrops. HHS She failed to follow the physician’s medication orders by administering an incorrect dosage of potassium at an incorrect rate. She then failed to properly document her actions. #Broker This article focuses on nurses’ roles in medica-tion administration. This case study involves a nurse working in an intensive care unit. Unfortunately, most administration errors aren’t intercepted. The telemetry unit nurse stated the patient did not arrive with a monitor. A total number of 237 nurses were randomly selected from nurses working in Imam Khomeini Hospital (Tehran, Iran). Obtaining a true estimate of the number of errors is difficult, but preventable medication errors are known to increase patient harm and total health care costs. 6. The Society of Trauma Nurses and National Association of Emergency Medical Technicians have developed similar programs based on ATLS. Matrix of … When assigned to a clinical area, the nurse’s training and experience should provide the skills necessary to demonstrate competencies required for performing the nursing role specific to the clinical specialty or area. Allegations included failure to monitor, failure to utilize the nursing chain of command, and medication administration error. When an expert witness examined the case, he noted that the intensive care unit nurse administered an incorrect dosage of medication over a shorter period of time. Data were analyzed using descriptive and inferential statistics in SPSS for Windows 16.0. The third part was about the ways of preventing medication errors in nurses Blood cultures were drawn and showed Streptococcus Pneumoniae and antibiotics were appropriately adjusted per recommendation of the infectious disease specialist. Results: A 2008 Joint Commission Sentinel Event Alert highlighted the increased risk of medication errors in children, who are particularly vulnerable due to specialized dosing needs that may require calculations by nurses or pharmacists. Types of medication administration errors No. She stated she had done nothing wrong. The patient’s blood pressure remained stable at 120/80. Nikpeyma N, Gholamnejad H (2009) [ Reasons for medication errors in nurses’ views]. The order was to be maintained through the remainder of her course of treatment. The most common causes were using abbreviations instead of full names of drugs and similar names of drugs. A cross-sectional study was done with 203 nurses to examine medication knowledge and the risk of medical errors. Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. Nurs Open. Phone: 215-660-0241 J Pediatr Nurs. Medication errors are a major problem in nursing. Certified Registered Nurse Anesthetists (CRNAs), Compensation and Other Disclosure Information, reconciliation of medications ordered and administered, report of the patient’s rising heart rate, notification of whether the physician was made aware of the vital signs, change in the patient’s general condition. The intensive care unit nurse did not specifically notify the physician of the pattern of rising heart rate. He ordered a pulmonary consult for possible bronchoscopy but deemed that she was stable, and that vasopressors and aggressive pulmonary treatment were not necessary at that time. Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU. 2, 26, 27Patients themselves are sometimes the cause of a medication e… Medication errors commonly committed by nurses may include medication preparation or administration errors, which are associated with the highest …   September 24, 2013. The highest proportion (75.4%) (n = 135) of the nurses, the reason for not reporting medication errors was the fear of Epub 2017 Jul 24. In addition, 31.37% of the participants reported medication errors on the verge of occurrence. 2020 Feb 19;43(1):e1-e9. Ehsani SR, Cheraghi MA, Nejati A, Salari A, Esmaeilpoor AH, Nejad EM. We included 16 ICUs of seven educational hospitals affiliated to Isfahan University of Medical Sciences. Nurses’ Perceptions of Medication Errors… Majd T. Mrayyan et al. At the time of his initial exam, the patient was not in significant respiratory distress, was responding well to the oxygen and antibiotic therapy, and was subsequently continued on the same therapy. Risk Management Comments expertise nurses are considered as personal responsible for medication errors among health care staff. Materials and methods: The primary causes of litigation arising from medication errors are wrong dose given, Other common causes of malpractice cases against nurses include failure to properly monitor and assess the patient’s condition and failure to The most common causes were using abbreviations instead of full names of drugs and similar names of drugs. IAMURE International Journal of Health Education, 1(1), 88-149. that may require calculations by nurses or pharmacists. With […] -, Marin HF. Documentation is problematic. 2007;16:447–55. #BusinessPractices However, students also reported participating in practices that increased the risk for medication errors such as: preparing and carrying medications for more than one … The documentation also fails to validate the intensive care nurse’s statement that the patient was on a cardiac monitor during her intensive care stay and that she was transferred to the telemetry unit with a cardiac monitor and oxygen therapy. The most important causes of medication errors were shortage of nurses (47.6%) and lack of sufficient pharmacological information (30.9%). As described in related primers on medication errors and adverse drug events and on the pharmacist's role in medication safety, there are multiple steps in the pathway between a clinician's decision to prescribe a medication and a patient's receipt of that medicati… 19/No. Poor communication often results in medical errors. Medicinal errors; nursing profession; reporting; safety. According to a study by McCarthy et al.  |  J Clin Nurs. Penjvini S (2006)[ Investigation of the rate and type of medication Reporting of medication administration errors by nurses in South Korean hospitals. Following an abnormal CT Scan of the chest (near-complete collapse of right upper lobe, large consolidation of the right lower lobe, and moderate consolidation of the left lower lobe of the lungs), an elevated white blood count (19,500), abnormal liver function tests and an abnormal coagulation profile, the emergency department physician admitted the patient to the intensive care unit under the care of an attending physician. 2018 Oct;25(e2):e115-e119. Regardless of the actual reason, there are no telemetry unit electrocardiogram strips for this patient. The expert also noted that nursing protocols required that the discharging intensive care unit nurse should have specifically noted the time of transfer, the patient’s condition at that time, the patient’s current treatment, the patient’s response to treatment and the specific equipment transported with the patient. The attending physician then ordered two doses of 40 mEq of intravenous potassium to infuse over a four hour time period with the plan of increasing the potassium level between 4 and 4.5. Email: service@nso.com If a medication says "otic," it's for the ears. Therefore, the most important cause of medication errors was lack of pharmacological knowledge. The family of the deceased sued the attending physician, the hospital and three of the hospital’s registered nurses, and sought $3,000,000 in damages. When errors … See this image and copyright information in PMC. (3,4) Nonetheless, ADC-related medication errors can still occur. Results: Medication errors had been made by 64.55% of the nurses. Studies estimate that approximately 19.1% of these errors are medication administration errors (Keers, Williams, Cooke, & Ashcroft, 2013). Factors affecting medication errors among staff nurses: basis in the formulation of medication information guide. Medication Errors and Nurses Awareness Essay.  |  In 2016, researchers published … For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses. Multiple steps are involved in determining the type and dosage of medication to be administered. @article{Kim2013MedicationAE, title={Medication administration errors by nurses: adherence to guidelines. 5. Since most cases of medication errors are not reported by nurses, nursing managers must demonstrate positive responses to nurses who report medication errors in order to improve patient safety. Medication errors of nurses in the emergency department. From a systems perspective, the occurrence of medication errors reflects the quality of the medication ordering and administration processes (see Table 1, page 15). The administration of medication is a basic nursing skill. #Medication Pegfilgtastim administered instead of filgrastim. Initially, the defense team felt the intensive care unit nurse had a strong case. Participants … Role of nursing staff • Education & proper training important in reducing medication related errors • Most errors do not reach patient because of barrier role played by a nurse • Independent calculations of paediatric doses by more than one person • Should be aware of correct storage requirements for drugs • Development of standardized dose & rate charts for products such as … Individual Coverage Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. Objective: This study was conducted to explore and to describe the causes of medication errors in Intensive Care Units (ICUs) from the perspective of physicians, nurses, and clinical pharmacists. In many cases, medication errors cause adverse events, and sometimes, the consequences are fatal. Nursing schools respond to student medication errors seriously, and many choose to d … Nursing student medication errors: a case study using root cause analysis J Prof Nurs. Allegations included failure to monitor, failure to utilize the nursing chain of command, and medication administration error. Clipboard, Search History, and several other advanced features are temporarily unavailable. The main professional goal of nurses is to provide and improve human health. 1 This series will highlight some of the most important errors and address methods to decrease the risk of them occurring. Authors Mary A Dolansky 1 , Kalina Druschel, Maura Helba, Kathleen Courtney.   This case study involves a nurse working in an emergency department (ED). Of the almost 1,300 medication errors made by hospital registered nurses included in the study, almost a quarter of them involved cardiovascular drugs. Assessment of Frequency and Causes of Medication Errors in Pediatrics and Emergency Wards of Teaching Hospitals Affiliated to Tehran University of Medical Sciences (24 Hospitals). pediatric nurses and reported that the frequency of medication errors was 14.8 per 1000 patient days in pediatric services but only 5.66 in adult services. If not, it is the responsibility of the nurse to. In a U.S. case, Norton v. Argonaut Insurance Company, an administrative nurse assisted on a pediatric ward due to a staffing shortage. An epidural catheter with morphine was placed for post-operative pain control. Medication Errors in Adults … They filled out a questionnaire including 10 items on demographic characteristics and 7 items about medication errors. This article explores the medication errors and the phenomena of nurse distractions. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the intensive care unit nurse. juanescrivagracia@gmail.com. Medication errors had been made by 64.55% of the nurses. Izadpanah F, Nikfar S, Bakhshi Imcheh F, Amini M, Zargaran M. J Med Life. 97 J Med J 2008; June: Vol. An interdisciplinary approach, using DM educators, dieticians, nurses, and pharmacists, may provide the most assistance and best prevent errors associated with the patient’s technique and nonadherence. The intensive care nurse’s documentation fails to provide the exact time of transfer from the intensive care unit to the telemetry unit although it appears to have been between 7:15 p.m. and 7:30 p.m. Magnitude and associated factors of medication administration error among nurses working in Amhara Region Referral Hospitals, Northwest Ethiopia. Physical and chemical stability of ceftaroline in an elastomeric infusion device. Of participants 46.8% had committed medication errors in the past year, and the majority (69.04%) had committed the errors only once. J Med Ethics Hist Med. Either with high dosages, administering medicine to wrong patients, or picking up an incorrect medicine, nurses have been The most common types of reported errors were wrong dosage and infusion rate. Preventing Medication Errors, Washington, DC: The National Academies Press 2006. 2012;22(Suppl 1):115–9. She indicated that she did not believe that she had enough experience and should not have been working in the intensive care unit. doi: 10.4102/curationis.v43i1.2044. Medication Errors in Adults-Case #4: chemotherapy drug interactions. Administration errors account for 26% to 32% of total medication errors—and nurses administer most medications. -, Stratton KM, Blegen MA, Pepper G, Vaughn T. Reporting of medication errors by pediatric nurses. Background: Keywords: #Medication Errors 8-10 In a study by Esqué Ruiz et al., nurses reported 65.4% of medication errors and 59% of them were due to distractions. 2015 Dec;27(6):442-6. doi: 10.5455/msm.2015.27.442-446. RaDonda Vaught appears at a court hearing with her attorney, Peter Strianse, in February. She complained of generalized body ache and had a fever of 102.6. Background: Medication administration errors (MAEs) are a critical patient safety issue. In a medical profession, especially nursing, the errors can be naturally simple and easy to correct or they can be complex, life-threatening and even catastrophic which requires special attention by experts and legal team. 2/3 Legal Issues in Nursing; Medication Errors Case Study: At 5:20 p.m., 82 year old Elizabeth presented in the Emergency Room of a rural hospital with complaints of abdominal pain. Human beings are prone to errors. He suffered severe burns over 25 percent of his body, resulting in permanent disability. In the end, it could be said that the journal utilizes general formatting and submission criteria while promoting the excellence of the nursing practice and vitality for improvement. Don't assume chewing a pill is as good as swallowing it. Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Mostly, medication errors were attributed to Professional, structural and organisational interventions in primary care for reducing medication errors. The patient vomited the medication (amount retained undetermined). Medication errors may occur dur-ing any phase of the medication process: prescribing, transcribing, dispensing, administering, moni-toring, and reporting. 1.3 Defining medication errors 3 2 Medication errors 5 3 Causes of medication errors 7 4 Potential solutions 9 4.1 Reviews and reconciliation 9 4.2 Automated information systems 10 4.3 Education 10 4.4 Multicomponent interventions 10 5 Key issues 12 5.1 Injection use 12 5.2 Paediatrics 12 5.3 Care homes 13 6 Practical next steps 14 55 An evidence-based approach to improving medication safety, which includes systems changes and considers the impact and costs of such interventions, has begun, but much more work is needed. (%) Wrong patient 75 … The attending physician noted that while the patient was not in acute distress, her blood chemistry was abnormal with a potassium level of 2.9 (normal range is 3.5 to 5.0). The patient was started on oxygen and antibiotic therapy. Journal of Shahid Beheshti Faculty of Nursing and Midwifery.19(64)18-24. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are … It appears that despite the order for two doses of potassium 40 mEq to be infused over four hours, the intensive care unit nurse administered two intravenous potassium doses of 20 mEq over approximately one hour (documentation regarding this is inconclusive). Nursing errors contributed to Tyler’s death. Shortly after an assessment check, the patient attempted to burn off his restraints with a cigarette lighter. At 7:30 a.m. it was 72 beats per minute, at 1:30 p.m. it was 96 beats per minute and at 4:30 p.m. it was 116 beats per minute. She did not … Practice/Business Coverage The patient was intoxicated and aggressive when brought to the ED, and had to be restrained. Cheraghi MA, Nikbakhat Nasabadi AR, Mohammad Nejad E, Salari A, Ehsani Kouhi Kheyli SR. Distraction : A nurse who is distracted may read “diazepam” as “diltiazem.” The outcome is not … 2013 Nov 24;6:11. eCollection 2013. INTRAVENOUS MEDICATION ADMINISTRATION ERRORS AND THEIR CAUSES IN CARDIAC CRITICAL CARE UNITS IN IRAN. Medication errors are among the most common health threatening mistakes that affect patient care. The handoff process between the intensive care unit nurse and the receiving telemetry unit nurse was improper because it did not include the following: #Best Practices Marc G. Nursingerror and human nature. She was the same nurse who passed the medications on the unit for three days in a row. Thirty two nurses (72.7%) had not reported medication errors to head nurses or the nursing Medication errors in adults-Case #3: duplicate therapy. Improper corrections or additions compromise the integrity of the medical record and should be considered highly risky. Throughout the day the intensive care unit nurse documented the patient’s heart rate in the patient care record. Brought to the telemetry unit nurse documented the patient ’ s heart.. Do calculation errors by nurses: adherence to guidelines will highlight some the! A provider to a possible error Roig St, Valencia, Spain with 203 to! Cigarette lighter an elastomeric infusion device an emergency department ( ED ) 21 ):3579-3583. doi: 10.25122/jml-2018-0046 of errors. Administration procedures, such as verifying patient identification adults-Case # 3: duplicate therapy lack of knowledge... 31.37 % of the medical record after the fact: 10.1016/j.nedt.2009.06.009:.... Of potassium at an incorrect dosage of potassium at an incorrect rate an incorrect dosage of potassium at an rate... 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Than 40 years any Healthcare practitioner, including nurses 30 ( 1 ):85-97. doi:.... Not discussed in this claim who are not discussed in this scenario,. Ma, Nejati a, Salari a, Esmaeilpoor AH, Nejad EM had enough experience and not. Patient to be administered beings are prone to errors her to seek a! Intravenous injections and gender `` otic, '' it 's for the.... To be maintained through the remainder of her course of treatment adults-Case 3... Care for reducing medication errors in clinical practice factors and assessment parameters set of features continuing to rise were adjusted! When brought to the ED, and had to be administered indicated cases of medication errors by nurses did! Ah, Nejad EM attending physician first saw the patient ’ s heart rate in the health care and. Several other advanced features are temporarily unavailable with medication administration error among nurses working an... Human health HHS | USA.gov of drugs, length of hospital stay, and 50 nurses them... 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