Medication Error: A Formal Definition for Medical Error

MEDICATION ERROR AS THE QUALITY INDICATOR 1 MEDICATION ERROR AS THE QUALITY INDICATOR MEDICATION ERROR AS THE QUALITY INDICATOR Name of the student: Name of the university: Author note: Medication error can be defined as the failure that occurs in a treatment process while caring for the patient by the Healthcare professionals. Medication errors can occur anytime while deciding which medicine and dosage regimen should be provided to the patient, manufacturing the formulation of the medications, dispensing the formulation,

Running head: MEDICATION ERROR AS THE QUALITY INDICATOR
MEDICATION ERROR AS THE QUALITY INDICATOR
Name of the student:
Name of the university:
Author note:

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MEDICATION ERROR AS THE QUALITY INDICATOR
Medication error can be defined as the failure that occurs in a treatment process while
caring for the patient by the Healthcare professionals. This has the potential to harm patients
resulting in severe threatening outcomes on their health as well as on their lives (Bogner
2018). Medication errors can occur anytime while deciding which medicine and dosage
regimen should be provided to the patient, manufacturing the formulation of the medications,
dispensing the formulation, administering the medicine, during the monitoring therapy, and
many others. Medication error can be classified into a number of psychological
classifications of errors that can be knowledgeable action as well as memory based errors.
Medication errors can range from less serious to highly threatening for the patient even
resulting in preventable hospital death (Vancott et al. 2018). Therefore researchers have
stated that it is important for the detection of medication errors since System errors which
might lead to minor errors in the initial stages can later turn to serious errors in the latter
stages. Therefore, reporting of such areas should be encouraged by creating blame free as
well as a non punitive environment (Makary and Daniel 2016). Therefore, medication errors
can be considered as one of the quality indicators which ensure that the care provided to the
patient is whether safe or not and whether the patient life is at threat or not. This assignment
will help to establish medication error identification and reporting as one of the quality
indicators for help. It will also provide different evaluation Pathways by which medication
errors can be reported and the initiatives that can be taken for every Healthcare centers so that
they can reduce the chances of medication errors and help in development of a safe
environment for the patient to be treated.
Medication error can be defined as any kind of failure in the treatment procedure
which has the potential to affect the lives of patients. On the analysis of different types of
literature that had been research by the eminent authors over the age, different types of
medication errors can be noted. The first type of medication error that might occur is in the

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choosing of the correct medicine which might be irrational, inappropriate as well as resulting
from ineffective prescribing, under prescribing or over prescribing. It may also occur during
the time of writing the prescription that may result in prescription errors as which might
include ineligibility (Keers et al. 2015). It also may occur during the time of manufacturing of
the formulation that is to be used by the Healthcare professional. It might have wrong
strength as well as contaminants or adulterants as well as may also have wrong or misleading
packaging. Errors might also occur during dispensing of the formulation that is having the
wrong drug, wrong formulation, wrong label (National Academies of Sciences, Engineering,
and Medicine 2016). It might also occur while administering or taking the drug that may
result from wrong doses, wrong route, wrong frequency as well as wrong duration.
Healthcare professionals can also make errors during monitoring therapy that may result in
failing to alter therapy when required or resulting in erroneous alteration.
In a hospital based study of about 36200 medication errors, prescribing errors were
identified in 1.5% of the cases and most of the errors (for about 54%) were associated with
the choice of drugs that was administered that became potentially severe and harmful for the
patients. This was accounting for about 0.4%. In a survey of about 40000 medication errors in
173 Hospital trusts, it was seen that approximately 15% of this caused slight harm and 5%
caused moderate-to-severe harm. In another study it was found that 1.7% of the prescriptions
dispensed from the community for pharmacies contain errors. Since approximately 3 million
prescriptions are dispensed each year and about 50 million prescriptions contains errors.
Among those, only 0.1% was thought to be clinically important giving an annual incidence of
such errors of about 50000 (Samp et al. 2014). Wrong label information and instructions were
also found to be among the common types of errors. There are harmful impacts on the life of
the patients where the patients have either to live for longer days in the hospital that results in
increased financial burden on them and their families. They also sometimes have to undertake

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readmission for the effects of the medication occur much later. This results in anxiety and
fear among these patients along with financial burden. In many of the cases, patients were
seen to suffer immensely before facing death in the hospital which otherwise could have been
prevented if the Healthcare professionals had been careful about their approach. Medication
error has been determined to be one of the most common causes of death in most of the
hospitals and therefore this has become one of the most significant indications for safe
practice in every hospital (Carayon et al. 2014). Researchers are therefore of the opinion that
important evaluative studies should be conducted in every hospitals to understand the
conditions of medication errors occurrences and thereby to stop these occurrences in the
hospitals.
Literature review has been conducted on different types of medication errors. The first
type of medication errors that has been noted in the different evidence-based studies are the
knowledge based error which occurs through the lack of knowledge of the Healthcare
professionals. In an Australian study, communication problem with the senior staff and facing
different kinds of difficulty in accessing appropriate drug dosing information has resulted in
knowledge based prescription errors (Westbrrok et al. 2015). Researchers are of the opinion
that Healthcare professionals should always try to avoid these kind of errors by being well
informed about the drug that is been prescribed and the patient to whom the drug would be
administered (Wachter 2015). For this, computerized prescribing systems as well as barcode
medication systems and even cross checking by others can help to mitigate such kind of
errors. Education is also found to be extremely important to prevent this kind of medication
errors. An example can be provided in order to give idea about knowledge based errors.
Knowledge-based errors might happen when the Healthcare professionals provides penicillin
to a patient even without knowing that the patient is allergic to it or not (Lewis et al. 2016).

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Important initiative should be taken so that such kind of errors does not occur in the
organisations.
Another type of error that has been notified in many of the Literature articles is the
rule based error where the Healthcare professionals usually use a bad rule on misapplying a
good rule (Fox et al. 2014). They have stated that proper rules and education help in the
avoiding of these types of error and computerized prescribing systems can also be used as a
support to reduce rule-based errors. This can be exemplified. When health care professional
inject a diclofenac into the lateral thigh of a patient instead of giving it into the hip region, it
causes rule-based errors and might result in the suffering of the patient in various kinds of
ways.
Another type of error is called the action based errors. This might occur due to slip in
attention that take place during routine prescribing, dispensing and administration of drugs.
This can be minimised by the creation of conditions in which these errors are unlikely. This
can be done by avoiding distractions, by cross checking, by labelling of different medications
clearly and also by the use of proper identifiers like that of barcodes. Many of the researchers
have also proposed that a way to avoid misreading of labels can be done by the tall man
lettering procedure with well mixing of upper and lowercase letters in the same word has
been proposed (Yoder et al. 2015). However this method has not yet been tested in the real
life conditions and therefore their affectivity is not yet ensured. Different types of action
based errors can also occur like the technical error for putting the wrong amount of potassium
chloride into an infusion bottle can also take place. This type of error can be prevented with
the help of proper utilisation of checklist, fail-safe systems as well as computerized reminders
(Karavasiliadou and Athanasakis 2014). One example of action based error can be picking up
of a bottle of containing diazepam from the pharmacy shelf when the professional actually

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intended to take one containing diltiazem. Therefore his type of error should be avoided in
order to ensure safety of patients.
Memory based errors can also take place which are otherwise called lapses for
example the professional already knows that the patient is allergic to penicillin but due to
lapsing or due to forgetting, he might give penicillin to the patient (Coffman et al. 2017).
These are usually hard to avoid and they can be intercepted by computerised prescribing
systems and also by cross checking
Indicators of medication safety are usually considered as an important subset of
Healthcare indicators. Medication safety can be referred to two aspects. The first aspect is
ensuring that the patients are ordered the most appropriate pharmacological intervention plan
that remains based on the best available evidence. The second aspect is ensuring that the
treatment plan is carried out as the professionals have ordered them (Kasper et al. 2015).
However researchers have stated that this aspect should be consistent with the position that
achieving safer care are following three important agendas for successful safety care of
patients. This three agendas are identifying what works best for the patients that is otherwise
called efficacy, ensuring what the patient receives is appropriate, as well as delivering the
medications flawlessly that is without any errors.
One of the most important types of indicators is the structure indicators. researchers
have said that structure indicators usually help in measuring the environment such as the
hospital infrastructure as well as the systems. Determining whether a Healthcare institution
has the correct policy and procedure for reporting as well as analyzing medication incidence
would be an example of a structure indicator (Berner and Lande 2016). Also stated that such
outcomes are not directly linked with the outcomes but they can be helpful in guiding
improvements of systems. Indicators are mainly requiring yes/no answers as well as

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providing a snapshot for the organizational culture. Another important type of indicator is the
process indicators. Process indicators usually help in measuring the compliance with different
processes of care that usually shows improvement of health outcomes. One of the very good
example of a process indicator stated by the researcher would be measuring the percentage of
appropriate as well as eligible patients who are receiving effective and specific treatment.
This can be antithrombotic medication for patients with the risk of venous thromboembolism
and many others (Xie and Carayon 2015). Process indicators are usually linked with the
outcomes and are usually saying to be helpful in guiding system based improvements.
Another type of indicator is the outcome indicator. This type of indicators mainly helps In
providing data related to the outcomes of care as well as health system performance. One of
the example that can be stated in order to provide light on the type of indicator is the number
of medication incidents that occurred resulting in the harm of death, per patient day of care.
Outcome indicators may be easy for the general public to understand and at the same time
they may not provide specific information which would help in guiding the improvement of
the systems.
There are 6 different types of structure indicators that have been found from the
different literature of evidence-based articles. Three of the structure indicators belonging to
the category of safety management are incident reporting and analysis, prospective
medication safety analysis, as well as top 10 medications analysis. The Other 3 structure
indicators belonging to the category of availability of high alert medications are the
concentrated potassium, concentrated electrolyte as well as narcotic safety (Hicks et al.
2015). There are also 11 types of process indicators that have been identified from the
literature. In the category of verification there are three important process indicators which
are monitoring and reducing the adverse drug events by the pharmacist on the ground,
effective verification of the different types of high alert prescriptions, and machine readable

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coding systems for effective administration. In the category of visual reminders, the process
indicators are the differentiation for various types of high alert prescription medications. In
the category of protocols there are five important types of process indicator which are
chemotherapy protocols, antibiotic therapy for different types of surgical patients, venous
thromboembolism prevention, antibiotic prophylaxis, as well as administration protocols for
effective high alert prescription medication. In the category of documentation of clinical info,
two important indicators are postoperative pain management as well as adverse drug
reactions (Kruer et al. 2014). There are five outcome indicators which fall in the category of
adverse events. These indicators are the medication error rate, medication incident types,
death incidents, medication error, medication incident rates with death incidence, and death
associated with medication incidence.
The first step of the PDSA cycle is called the planning stage. This stage usually helps
in planning the taste of observation including a plan for collection of the data. In this step, the
healthcare organization who is facing the issue of medication error should first develop a
committee that would be consisting of experienced healthcare professionals,
representatives of the higher authorities, nursing professionals and managers along with
leaders. They can introduce questionnaire-based survey that would be provided to both the
patients as well as to the Healthcare professionals like the nurses, pharmacists and others
associated with medication administration (Phatak et al. 2016). Information would be
collected from the patients about their feelings about how the professionals are maintaining
their medication administration. Then information would also be collected from the nursing
professionals regarding the number of mistakes they had made, the number of reports that
they have made about their own mistakes as well as that of the Other professionals, the
environment of the organizational culture which is supportive of the concerns on medication
error reporting and many others. this would help the committee to understand what different

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types of errors are most prone in the Health Care centers and thereby develop ideas about
how they could be developed in the organization to reduce such occurrences.
The next step is called the “do” step where individual should try out the step on a
small scale. Here the committee that was formed in the previous step should be analyzing the
types of errors that are made by the professionals and try out ways by which the areas would
be reduced. This could be done in the form of educating the professionals about the different
strategies they can take to reduce the errors. They should influence and encourage the
professionals to develop blame free environment where they can report incidences, develop
skills by which they can use the modern day information Technologies as well as the
computerized system by which medication error could be reduced and many others. The
professional should learn to use patient specific identifiers, learn to verify allergies and
reactions, highlight physical diagnosis and conditions, update current medications,
standardize height and weight measurements, follow proper guidelines, identify high alert
medications, and many others. The organization should itself develop an organizational
culture that would promote communication among the Healthcare professionals like sharing
of information, improvement of handwriting, avoiding problematic abbreviations, be aware
of the similar drug names, reconsidering using electronic systems and many others. The
higher authority should also introduce proper labeling and storage so that separating
problematic drugs, in keeping the storage well organized so that they become their main
priority. They are also advised to use proper drug devices like using the right syringes and
thereby training staff to use the devices properly.
The next step would be the step call “study” where the committee would be setting
aside time for analyzing the data they have collected and studying the results of the initiatives
that have been proposed by them (Belda et al. 2015). Here the monitoring Authority would
take an observation of each of the professionals while they are working so that they can

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understand the behavior and attitude of the Healthcare professionals during administration of
medicines. They will be also conduct interviews to understand how the different initiatives
that have been taken in the previous state are helping the professionals to overcome the
various issues during administering medications and how it has helped them to reduce the
errors.
The next step would be called the Act step where new initiatives would be undertaken
depending from the information derived from the last stage. From the evaluation made in the
previous step before, the higher authority would then introduce initiatives so that medication
error can be reduced and safe and quality care is provided to the service users.
From the above discussion, it becomes quite clear that medication error is one of the
biggest problems that the healthcare centers in the nation of Australia are facing in the
present generation. It is considered to be one of the most important indicators for quality and
safety in the Healthcare industry. Three important types of indicators have been proposed in
order to check the condition of medication error in the nation. These are the structure
indicators, the process indicators as well as the outcome indicator. Depending upon these
indicators and after planning a proper pdsa cycle, the Healthcare organizations can develop a
secure plan with initiatives that would help the Healthcare professionals to develop proper
knowledge and skills with which they can reduce the occurrence of medication error.
Development of an organizational culture supportive of the reporting of medication error and
encouraging in the development of technological system for reduction of the medication error
can help in providing quality and safety to patients.

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