Medication Errors in Nursing: Causes, Consequences and Prevention

This presentation discusses medication errors in nursing, their types, causes, consequences and prevention strategies. It also covers the PDSA cycle and the role of nurses in preventing medication errors. The presentation provides recommendations for improving medication errors and concludes with a summary of the key points.

Medication errors

Medical error-definition
 Medication error refers to the errors that could be prevented by the health care
professional while prescribing medicines.
 These errors involve issues such as giving wrong dosage , wrong medication or using
incorrect ways of administration.

Aim for medication error
The objectives of model for improvement in medication errors are as follows:
To improve the medication errors.
The aim is limited to the stakeholder satisfaction.

PSDA Cycle
 PSDA Cycle stands for Plan, Do, Study and Act.
 It is the four stage model which us used for improving the process fro carrying out a
change.
 It focus on including internal and external customers through which they are able to
provide feedback on what can work and what cannot.
 In simple words, this model concentrates on carrying out test and observing and
learning from the study (consequences) which help in determining what changes should
be made in Act (test).

Continued..
P-Plan
It includes collection of demographic data associated with the patient, omissions, drug
allergy documentation and their medication
It is also involved in identify patients who are taking any of 4 classes of medicines which
are more likely to cause severe harm and death.
D-Do
In this plan is put into action
Data is collected which helps in evaluation of plan

Continued..
S-study
In this step the results of plan are evaluated.
The improvements are reviewed and evaluated.
A-Act
In this step, plan is reflected and outcomes are evaluated.

Policies of NSW in medication
 Policy of NSW Health department associated with medication error consolidates best
practices such s principles on medication storage, prescribing, supply, dispensing,
administration and procurement as well.
 This policy applies to all public health organization health facilities and other institutes
such as hospitals, clinical services, community health centres and hospitals as well.
 However, his policy is not applicable to medication handling and administration
thorough flight nurses and paramedics employed by NSW ambulances.

Model for improvement
 It is a framework which is used of development, testing as well as for implementing
changes which lead to improvements.
 It provides easy to understand scientific method that acts to moderate the impulsive for
taking immediate course of action with the help and wisdom of a careful study.

CASE FOR CHANGE
 Medication error are considered a significant problem in the Australia in compared to
other countries. According to the reports it has been estimated that around 2%-3%
health care issues in Australian hospital admission is related to medication errors only.
 In other words it can be said that around 230,000 admission in the country are caused
due to patients taking too much or too little medication annually.

MODEL FOR IMPROVEMENT
 With the use of PDSA Cycle changes for improvement can be inculcated. According to
author, Plan Do Study Act is a four stage interactive problem solving model that is used
for improving a process and carrying out the changes in the processes.
 In other words, according to the view point of author, the PDSA cycle begins with the
step of planning that is using of theories and analysing the success metrics, further
these activities are followed by the do step that is where the plan in implemented.
 In third step the implemented step in studies and analysed. And lastly the act step
which closes the cycle , generated by the entire process.

CONTD…
To reduce medication errors and to improve quality health care
 It can be analysed that medication error is one of the most serious problem in the
health care system of NSW. Health care professional plays a major role in preventing and
catching these medication. It can be analysed there are various types of medication error
that is prescribing, omission, wrong times, unauthorised drug, improper dose etc.
thus it is very important that some strategies are followed buy the health care professional
so that these errors could be prevented that is while prescribing medicines professional
should double check the prescription.

Medication errors-types
 Knowledge based errors
 Rule based error
 Action based errors
 Memory based errors
 Technical errors

Factors contributing to medication errors
Some factors which contribute towards potential medical errors are as follows:
The major cause of medication errors is communication problems
Distractions in environment
Issues in medication packaging and products
The inability of patients or professionals in reading the drug chart
Lack of training and education in healthcare professionals such as nurse.

Examples
 Writing illegibly , which results in writing Panadol as Priadel
 Forgetting to specify clearly the maximum and minimum doses of required medicine

Consequences of medication errors
Consequences on patients and their family
The effects can range from no notable symptoms to even death
They can cause issues such as itching, skin disfigurement and rashes either permanent or
temporary
Consequences on healthcare professionals
Professional who unintentionally give wrong medicines experience guild, self-doubt and
shame.
It also results in making professions as second victims and the effect of it can life-
threatening.

Measures of medication errors
Some of the measures of medication errors can be as follows:
Proper recording and maintenance of records and documentation
The temperature of medicine should be checked and maintained.
Guideline of medication regarding size and time must be followed appropriately
The patient details must recorded appropriately and clearly.

Role of nurse in prevention of medical errors
 The nurse have to work as a gatekeeper in administration procedure for preventing
medication errors.
 They have to identify and correct the medical errors
 Nurses have to reduce distractions and interruptions in medication administration
 They have to deliver premixed medications from the pharmacy to nursing wards
without further special preparation by professionals.
 Nurses have to assist the use of calculator for facilitating the resolution of calculations.

RECOMMENDATION AND
CONCLUSION
Recommendations
 PDSA cycle will support continuous improvement in the area of medication error by
effective formulation of strategies.
 With effective formulation of strategies it will result in providing quality health care
services.
Conclusion
 It can be concluded that the purpose is to reduce the medication error so that
quality services can be provided. Thus, with effective use of models and strategies it
will help in enforcing changes for improving medication errors

REFERENCES
 Asensi-Vicente, J., Jiménez-Ruiz, I. and Vizcaya-Moreno, M.F., 2018. Medication
errors involving nursing students: A systematic review. Nurse educator. 43(5).
pp.E1-E5.
 Marvanova, M. and Henkel, P.J., 2018. Collaborating on medication errors in
nursing. The clinical teacher. 15(2). pp.163-168.
 Bolandianbafghi, S., Salimi, T., and Sarebanhassanabadi, M., 2017. Correlation
between medication errors with job satisfaction and fatigue of nurses. Electronic
physician. 9(8). p.5142.