MEDICATION ERRORS 1

Medication Errors

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Analyze a current health care problem or issue

Medication error is an essential element of an improved health care. This evaluation will

expound on the medication errors that can occur when a patient is exposed to while receiving

medical attention. Health care organizations should work on eliminating medication errors to

avoid harming the human health. A medication error are errors that occur as a result of patient

taking the wrong dosage causing harm to the patient's health and can even lead to death among

many others (Burlingame, 2018). Proper care should be taken to improve the infrastructure of

health care organizations. The safety of the medication should be introduced and the medical

staff and patients trained and any other personnel that deals with health care.

Elements of the problem/issue

From the research, while patients are being treated at any hospital, they can be at risk of

experiencing harm or injuries associated with medication errors. The main causes of medication

errors that can occur throughout the treatment process are preventable unfavorable events that

leads to the error (Siew, 2017). Medication errors can be categorized into errors due to

knowledge, errors based on rule, errors as a result of action and errors based on memory.

Knowledge-based errors occurs due to lack of knowledge. An example of a knowledge-

based error is giving a penicillin without establishing if the patient is allergic. Communication

problems also with the senior medical staff can lead to knowledge-based prescription errors

(Salhotra& Tyagi, 2019).Rule-based errors results in misusing a good rule. An example is

injecting a diclofenac into the literal thigh instead of the buttock.Action-based errors results as a

result of distractions or unclear labels. In this case, most errors occurs due to slips in attention

during drug administration. An example of technical error is a technical error, for instance,

putting the wrong amount of potassium chloride into an infusion bottle.Memory-based errors,
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also called lapses, are hard to avoid. An example is giving penicillin to the patient forgetting the

patient to be allergic.

Analysis

As a researcher in the medical field, it is essential for me to be aware of potential

medication errors which poses dangerous risks to the patients. Also, I must ensure the difficulties

in medication is reduced by achieving balanced prescribing. This will aid to ensure that person’s

health is well taken care of.

Context of medication errors

Medication errors are the most common types of medical errors in hospitals and it is the

leading cause of death among patients today. In medication systems, medication errors are

under-reported which occurs in all stages of medication use process (prescribing, dispensing and

administration) (Yousef & Yousef, 2017). Therefore, it is very essential to evaluate the

knowledge of the professionals on the medication errors that occurs and reporting systems in all

healthcare sectors.

Populations affected by medication errors

Children of less than five years of age, whereby the dose was not well administered and elderly

people with chronic medication and minimum control of their medication level are the most

vulnerable group of people. Therefore, the measures taken to reduce medication errors should

focus primarily on them.

Considering options.

The AORN recommendation outlines the medication safety procedures and concentrates

prescription phase, administration phase, patient education phase, and transition of care

phase.Specific safeguards are required by the guidelines, such as assigning a medical

professional to monitor information transmission to the receiving caregiver during transfer of

care and conducting comprehensive patient and caregiver education prior to release (Allen, 2014;

Burlingame, 2018).This article emphasizes the necessity of taking precautions at all stages of a

patient's medication exposure, from prescription to administration and aftercare, which is why it

is relevant to this research.A typical approach, particularly in the manufacturing sector, is total

quality management, in which every phase of the operations involved in a given project is

double-checked and barriers are removed as soon as possible to ensure that the quality is

satisfactory.

Since most medical errors occur during the drug administration procedure, studies

analyzes the implications of healthcare professional education and better handwritten

prescriptions. One study was conducted in one of the government-owned hospitals to improve

the drug administration process and determine its effect, and it revealed that changing

professional behavior, particularly regarding handwriting, significantly reduced medication

errors, particularly those resulting from drug administration errors due to poor handwriting (Van

et al., 2018). Electronic medication management systems are commonly utilized in healthcare

settingsto help with patient medication management, stock intake, and disbursement.

Nonetheless, these technologies are not always accurate, and even when they are present,

there are recorded flaws. With this problem in mind, the authors of this article decided to

perform a study in multiple Victorian hospitals to determine the medication errors that have been

linked to electronic medication management systems and those that are thought to occur

frequently with the eMMS.

Solution

To reduce the medication errors in health care system, medical staff training should be

conducted since most of the errors are caused by them. Also while prescribing drugs to the
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patient, it is better to conduct a patient medication safety training so that they can avoid errors

that are rule-based (Nanji et al., 2016). Furthermore, improvements in packaging should be made

by using computerized systems since they are more accurate than humans.

Implementation

Computerized physician order entry (CPOE) with decision support is an important

mechanism for minimizing medication errors. CPOE systems work by ensuring the order is

legible and complete and it includes all the necessary information like dose (Chien et al., 2021).

The computerized system checks for conditions like drug allergies and the reactions of combined

drugs. Lastly, it updates the prescriber with latest drug information.

Conclusion

Medication errors are a critical problem in the healthcare sector since their frequency

determines patient safety and also defines whether or not patient care management is successful.

As a result of my research and evaluation, I have come to the conclusion that the human factor

plays a critical role in the causes and prevention of medical errors. Knowledge of medical

administration, familiarity with the system, professional behavior during medication

administration, and the usage of technology through the establishment of systems have all been

cited as major factors in all four studies, indicating that they can help significantly in reducing

medication errors in our healthcare settings.

References

Allen, G. (2014). Implementing AORN recommended practices for environmental

cleaning. AORN journal, 99(5), 570-582.

Burlingame, B. (2018). Guideline Implementation: Medication Safety. AORN Journal, 107(4),

476-487.

Chien, S. C., Chin, Y. P., Yoon, C. H., Islam, M. M., Jian, W. S., Hsu, C. K., ... & Li, Y. C.

(2021). A novel method to retrieve alerts from a homegrown Computerized Physician

Order Entry (CPOE) system of an academic medical center: Comprehensive alert

characteristic analysis. Plos one, 16(2), e0246597.

Nanji, K. C., Patel, A., Shaikh, S., Seger, D. L., & Bates, D. W. (2016). Evaluation of

perioperative medication errors and adverse drug events. Anesthesiology, 124(1), 25-34.

Salhotra, R., & Tyagi, A. (2019). Medication errors: They continue. Journal of Anaesthesiology,

Clinical Pharmacology, 35(1), 1.

Siew, A. (2017). Reducing Medication Errors. Pharmaceutical Technology, 41(11), 20.

Van de Vreede, M., McGrath, A., & de Clifford, J. (2018). Review of medication errors that are

new or likely to occur more frequently with electronic medication management

systems. Australian Health Review, 43(3), 276-283.

Yousef, N., & Yousef, F. (2017). Using total quality management approach to improve patient

safety by preventing medication error incidences. BMC health services research, 17(1),

1-16.
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