Preventing Medication Errors and Improving Patient Safety

How can health care professional prevent medication error and improve patient safety?
Identification of an issue
Medication errors have serious implication on the health and wellbeing of a patient and is considered as a breach in patient
safety. This prevalence and the risk associated with this issue can be avoided through proper identification and monitoring
systems. Detecting the error as soon as possible is the first desired intervention. However, depending on the chosen routine
or area of care, or care settings the approach for detecting is different. the methods that are more commonly used include
chart reviews, computerised monitoring, using direct observation and patient monitoring are some of the following 1.
However, each of these approaches have their own set of limitations and advantages, which makes them more or less suited
to a given care setting. In order to negate the chances of medication error, there is not only a need for intervention approach
but the approach should also be suited to chosen care environment.
PICO questions
Population Patients admitted in a healthcare
facility
Intervention Detection and monitoring techniques
Comparison Direct observation and reporting
Outcomes Improvement in patient safety
Search strategy
The aim of the search process was to find appropriate and evidence-based practice strategies that can be applied to
universal settings. Also, the source needs to be backed by verifiable and bias less research procedures. The evidence was
collected from online medical databases like PubMed, Cochrane and Science Direct to name a few. The articles included
consist of qualitative researches, quantitative survey and practice guidelines. The PICO strategy was used to establish the
keywords for searching the articles. The PICO questions help to establish four main points including the targeted audience,
the chosen intervention for the issue, comparison of another intervention and the outcome noted when the chosen
intervention is put into practice. The PICO questions also help to limit the searches as it sets the target audience which
narrows the search. The chances of medication error can also be present in personal care settings and when unpaid care
providers are working. However, the research articles used focused only towards the detection and prevention of error
medication in professional settings. Boolean operator like “and” was also used to narrow the search. Other than the
publication year and content of the articles were found were assessed to chose five articles among the many available. The

hierarchy of evidence will be used to decide on the level of evidence of each of the articles. Also, the quality of the papers will
be assessed through the CASP tool and by seeing whether they satisfy the PICO questions raised or not.
Literature matrix
Author/
Date
Research
Question/
Aim/ Purpose
Populatio
n
Study
Design
Findings Conclusio
ns and
Implicatio
ns for
Practice
Level
of
Evide
nce
Limitations
Germana
Montesi
and
Alessand
ro Lechi
(June
2009)
Prevention of
medication
errors through
detection and
auditing
systems
Healthcar
e
organisati
ons and
patients
who are
susceptibl
e to these
errors.
Audit Error
prevention
approaches
can be
made
through
retroactive
and
proactive
tools.
Chart
reviews
have been
the
interventio
n that has
been used
in the past
and soon
computeris
ed
monitoring
is going to
take over
the
method.
5 The evidence fails to
answer why the
occurrences is not evenly
distributed and rather
occurs in clusters.
Ulmer C,
Miller
Wolman
D, Johns
MME,
(2009)
Recommendati
ons from the
Committee on
Optimizing
Graduate
Medical
Graduate
and
trainee
nurses
Guidelines
and
recommendati
ons
Teaching
and training
nursing
professional
s from their
trainee or
Making
any
changes
system in
care
delivery
7 In some situations, it is
not possible to train the
nursing graduates. And
this solution does not
deal with the case of
training the senior

Trainee
(Resident)
Hours and
Work Schedule
to Improve
Patient Safety
for more
effective error
reporting and
handovers
graduate
levels about
the
intervention
s are most
effective.
method
and then
training
the nurses
is a
challenge.
As a result,
the
trainees
should be
taught
better
interventio
n right at
graduate
level.
resident nurses.
Sedigheh
Farzi,
Alireza
Irajpour,
Mahmou
d
Sanghaei
and
Hamid
Ravaghi,
(Sep
2017)
This study was
performed to
find out the
causes that
lead to the
error in
medication
delivery.
Physicians
, nurses
and
clinical
pharmacis
ts
Descriptive
qualitative
study
The causes
were found
out to be
lack of
attention,
communicat
ion
mechanisms
and
environmen
t
determinant
s
Through
manageria
l
leadership
s and
team work
the
collaborati
on of
healthcare
profession
als can be
promoted
to
overcome
the
causes.
5 The system of
collaboration and
communication can only
bring limited results.
Thomas
L.
Establish
patient safety
Medical
care
Clinical
recommendati
Errors can
be
All the
nursing
4