Patient Safety Strategies and Medical Errors

The provided assignment is an extensive compilation of research articles and studies related to patient safety strategies and medical errors. It includes various topics such as medication reconciliation during transitions of care, nurse-patient ratios as a patient safety strategy, and the implementation of handoff programs. The document also features articles on medical error as the third leading cause of death in the US, potential clinical impact of medication discrepancies at hospital admission, and factors affecting usage of personal health records to manage health.

Running head: MEDICATION ERROR
Medication error
Name of the Student
Name of the University
Author note

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According to Institute of Medicine (IOM), patient safety is “an indistinguishable element
from delivery of quality of healthcare” (Makary & Daniel, 2016). Patient safety is an important
element of an efficient and effective healthcare system and healthcare professionals are engaged
in improving patient safety by learning from errors, checking procedures and through effective
communication (Ulrich & Kear, 2014). These activities minimize patient harm and ensure safety
in the healthcare organization. However, the scenario is different in my organization as there is
increasing incidence of medication errors that is hampering patient safety. Moreover, many
organizational barriers affect the quality of care and patient safety. Therefore, the following
essay involves the discussion of medication error as patient safety issue, evidence-based
interventions, technology use and strategies to overcome organizational barriers.
Medication errors are divided into four broad categories: lack of knowledge, rule and
action- based errors and memory-based errors. Knowledge-based errors occur due to lack of
communication between healthcare professionals regarding drug-dose information contributing
to prescription errors. The second type of medication is rule-based error where medication is
administered at the wrong route. The third type of error is action-based error. This is the most
common type error as it occurs because of slips in attention at the time of dispensing, prescribing
or drug administration. Technical error is a subset of this error type where there is wrong entry of
amount of drugs. Lastly, memory-based errors where medical staffs administer wrong medicine
forgetting about the medical history of the patient (James, 2013).
Although, progress has been made in the detection, reporting and learning from patient
safety events, improvements are required for enhancing the patient safety and data quality in my
organization. Medications errors are leading to poor quality of care and patient deaths that are

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otherwise preventable in my organization. In the present scenario, medication error is the major
patient safety issue concerning my organization.
Medication errors are giving rise to many patient safety issues. Firstly, incomplete or
inappropriate patient information where nurses do not make full entry of patient’s medical
information on the chart. As a result, there is missing information that has a direct effect on the
health and safety of the patient. The proper documentation of past medical history, current
medications, allergies is important as it might alter the whole treatment procedure. Inaccurate
drug information is another cause of medication error where nurses or caregivers are not aware
of the current drug information due to lack of knowledge and skills (Vogelsmeier et al., 2013).
Medication errors are also caused by inadequate communication between healthcare
professionals. Miscommunication may occur due to heavy workload, power struggle and lack of
situation awareness that compromises patients’ lives. Drug packaging, nomenclature or labelling
is another cause of medication error. The delivery of improper medicines or same sounding or
looking alike medicines during busy schedules is a common event for medication error
hampering patient safety (Starmer et al., 2014). Another contributing factor to medication error is
staff shortages and their lack of competencies. Many nurses may not be aware of the correct
administration of drugs that also leads to medication error. Therefore, these factors greatly
contribute to medication errors and adverse events causing unintended harm to patients resulting
in compromising patient safety and large financial burden to the organization.
My organizational standards for addressing medication errors does not align with the
principles, concepts and practices of World Health Organization (WHO) that contributes to
patient safety and quality improvement. WHO outlines performance requirements or principles
that acknowledge medication safety as one of the topmost priorities concerning patient safety.

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The use of generic names, tailoring of prescribing procedure for patients, learning and practicing
medication history, knowledge about high-risk medications, familiarity with medications,
following the concept of 5 Rs during prescribing and administration are some of the
requirements. In addition, clear communication, reporting and learning from medication errors
and encouraging patients to take an active participation in the medication process also helps to
acknowledge that medication safety is of paramount importance (Aljadhey et al., 2013).
However, the scenario is different at my organization. The steps in medication use and
practice involve prescribing, administration and monitoring as outlined by WHO. In my
organization, prescribing go wrong in many ways. The nurses have inadequate knowledge about
drug contraindications and not aware of patient’s medical history like allergies, co-morbidities
and other medications. There is inadequate communication between the professionals that results
in wrong dose, wrong patient and wrong time. Moreover, the documentation is incomplete,
illegible and ambiguous. Mathematical error also occur at the time of dosage calculation and
most importantly, incorrect data entry like omission, duplication or wrong number. In contrast to
this, WHO recommends that while prescribing medication, medical staffs should choose an
appropriate medication as per clinical situation considering patient’s medical history (Leotsakos
et al., 2014). The selection of administration route, time, dose and regimen should be appropriate
before prescribing medication. There should be proper documentation and communication
between staffs regarding the medication administration and patient. To avoid sound-a-like or
look-a-like medication mixing or ambiguous nomenclature, the medication should be written
clearly with accepted local terminology, avoiding trailing zeros (1 instead 1.0) and using leading
zeros (0.1 instead of .1) (Quélennec et al., 2013).

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Wrong patient, time, route, drug, dose, omission or inadequate documentation makes
drug administration go wrong. WHO recommends 5 Rs (Right Drug, Time, Route, Dose and
Patient). Monitoring also goes wrong when nurses do not monitor the patients for side effects,
drug levels with lack of follow-ups and communication failures. In contrast to these practices,
WHO recommends continuous patient observation to look for medication working, appropriate
used and ensure that no harm is caused to the patient with proper documentation of vital signs
after drug administration (Bennadi, 2013).
Ethical and legal issues are associated with medication error. According to American
Medical Association (AMA), nurses have the responsibility to address this problem to shape a
culture of safety in healthcare. The ethical principles of autonomy, right to knowledge and
disclosure, veracity, beneficence and non-maleficence are the main issues involved in
medication errors. There is right to self-determination and autonomy where patients have the
right to make their own choices and take actions that are based on perceived benefits and
personal views (Bonney, 2013). Therefore, nurses have the responsibility to inform the patients
about their ongoing treatment including a medical error that has occurred. The principles of non-
maleficence and beneficence direct healthcare professionals to do what is best for the patients
and avoid harm. They have the responsibility to reduce the possible harm caused by an error
promoting patient safety. Moreover, healthcare professionals have an ethical obligation to
provide information to patients for informed decision-making. The patient has the right for full
disclosure in case of any medical error. Veracity principle explains that healthcare professionals
should provide accurate, objective and comprehensive information to patients so that they
understand it. Moreover, for the establishment of trust, they must tell the truth about medical
errors through effective communication to the patients (Aldrich, 2013).

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Evidence-based interventions are required for addressing the medication errors in my
organization. The strategies involve maintenance of adequate nursing staff and pharmacist,
improvement in nurses’ workflow, adoption of effective medication administration strategies,
implementation of appropriate technology and fostering a culture of accountability where
healthcare professionals should value quality improvement. Pharmacist staffing should be
appropriate in context to medication preparation, laboratory values crosschecking, monitoring of
high-risk and look-like medications (Kwan et al., 2018). Moreover, there should be active
participation of healthcare professionals in addressing medication safety related to
implementation of key safety practices: no use of abbreviated drug name in lists, use of two
identifiers for drug administration, high drug alert and two independent checks for high alert
dosages of medication.
For maintaining adequate nursing staff and workflow, the nurse to patient ratio should be
taken into consideration. As nurses are involved in medication prescribing and administration,
their workflow should be proper during administration and patient monitoring. Nurse to patient
ratio should be proper as ANA recommends 1:1 or 1:2 so that there is no heavy workload or
stress as that can result in medication errors (Shekelle, 2013). Effective medication reconciliation
strategies are an evidence-based practice where the current medication regimen of a patient is
compared against admission, discharge or transfer orders of a physician in identifying
discrepancies. This concept combines the need for expert review and patient information of
medications, side effects and interactions. Strategies like pharmacist-led accurate patient
medication history, counselling, reconciliation, medication review, clearly defined roles and
capacity building, discharge plan use help to reduce the cost of care related to adverse drug
incidents (Hairr et al., 2014).

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The most important strategy for reduction is medication errors are implementation of
appropriate technology for administering, storing and monitoring of medications enhancing
patient safety. The use of pertinent technological strategies like radiofrequency identifiers
(medication storage), improved wristbands for better patient identification, computerized
decision support (CDS) that provide alert for high dose and high–risk medications and
surveillance systems that monitor drug administration and allow prompt identification of adverse
drug incidents (Horsky et al., 2013). Furthermore, creation of an environment of quality is vital
for achievement of medication safety. The healthcare professionals need to be accountable for
their actions and should voluntarily report incidents of medication errors depending upon staffing
and support.
Organizational support is important for creating a quality environment where healthcare
professionals should learn from errors and encourages prompt and non-punitive incident
reporting. Healthcare professionals should adhere to The United States National Coordinating
Council for Medication Error Reporting and Prevention (NCC MERP) guidelines for
improving quality of organizations and reduction in medication errors. In addition, Continuous
Professional Development (CPD) of nursing staffs is crucial and the faculty should take new
medications under their teaching domains keeping nurses updated in learning procedures and
related policy guidelines (Kuo, Touchette & Marinac, 2013).
Medication errors can be prevented by using information technology (IT). As medication
administration is the last step in medication management, the intercept rate is low. To memorize,
recall, synthesize large amount of data and pay undivided attention during vulnerable areas that
can avoid medication error, IT systems can be beneficial in improving organization and access to
information. As maximum errors occur during prescribing step, patient-specific decision support

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with computerized physician order entry (CPOE) is a potential intervention for ensuring patient
safety. Dispensing errors are also common and by using pharmacy-dispensing systems like
automated dispensing cabinets and drug-dispensing robots, medication errors can be reduced
(Agha, 2014). Errors in packaging, recognizing medications and dispensing can be reduced using
bar codes. Bar-coded medication administration (BCMA) systems are helpful during bedside
medication administration where they need to scan the identification bracelet of patient and unit
medication dose. Electronic medication reconciliation can be used at transition care points,
admissions and discharge; however, it cannot detect error caused by physician while prescribing
medications to patient during discharge. Personal health records (PHRs) empower patients to
take an active part in their medical care. PHR is a stand-alone portal for patients in entering their
own medical data and give patients access to claiming EHRs (Taha et al., 2013). Therefore, these
IT systems can be helpful in reducing medication errors.
However, there are certain organizational barriers to this change like lack of leadership,
budget and resources, technology, resistance to change or skepticism, lack of communication and
organizational culture. Healthcare professionals in the organization may resist change due to
uncertainties and outcomes of change. Motivation through rewards and team-based problem-
solving approach can be helpful in overcoming resistance from staffs. Enlisting of outside help in
driving initial projects can be helpful in providing funding or shortage of internal resources. A
communication plan can be helpful in reaching to all levels of organization and building through
visible and early wins. Lastly, IT systems can be helpful in overcoming the barriers to
medication errors at the time of prescribing, administration and monitoring by physicians and
nurses. The healthcare professionals should be indulged in CPD for education and training in
being adapted to the proposed change in my organization (Weller, Boyd & Cumin, 2014).

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From the above discussion, it can be concluded that medication errors is one the major
patient safety issues that is otherwise preventable in my organization. Medication use is a
complex method and errors occur during medication steps of prescribing, administering and
monitoring in my organization. Wrong dose, drug, time, patient and route, inadequate
communication and knowledge, incorrect data entry, look-a-like or sound-a-like medicines can
cause medication errors. WHO recommends using generic name appropriately, practicing
medication history, 5 Rs, clear communication, encourage patients’ active participation and
learning from medication errors can help to reduce medication errors.

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References
Agha, L. (2014). The effects of health information technology on the costs and quality of
medical care. Journal of health economics, 34, 19-30.
Aldrich, R. (2013). Open disclosure: Ethical and cultural considerations. In Legal and forensic
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Aljadhey, H., Alhusan, A., Alburikan, K., Adam, M., Murray, M. D., & Bates, D. W. (2013).
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Bennadi, D. (2013). Self-medication: A current challenge. Journal of basic and clinical
pharmacy, 5(1), 19.
Bonney, W. (2013). Medical errors: moral and ethical considerations. Journal of Hospital
Administration, 3(2), 80.
Hairr, D. C., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the
relationship to job satisfaction and retention. Nursing Economics, 32(3), 142.
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James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital
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Kuo, G. M., Touchette, D. R., & Marinac, J. S. (2013). Drug Errors and Related Interventions
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