Patient Safety Indicators: Medication Errors

This paper discusses medication errors as a patient safety concern and how it can be used to evaluate care in a given healthcare setting. It also explores potential solutions to medication errors and how small-scale PDSA quality cycles can be used to solve medication errors for depression patients.

Running Head: PATIENT SAFETY INDICATORS: MEDICATION ERRORS 1
Patient Safety Indicators: Medication Errors
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PATIENT SAFETY INDICATORS: MEDICATION ERRORS 2
Executive Summary
Patient quality and patient safety indicators are critical at holding the healthcare
profession accountable with regard to the efficacy of the healthcare services rendered to patients
and their families by healthcare professionals. When patients seek healthcare in healthcare
facilities, they do in the expectation that their health care conditions will be eliminated and
possibly completely cured. However, this is not always the case prompting the need to have
indicators to monitor and evaluate the patient quality and safety concerns. Medication errors is
one healthcare concerns that plays an adverse role of curtailing the attainment of quality patient
outcomes as well as ensuring patient safety and therefore has been found to be a formidable
indicator of the same. It is against this backdrop that this paper will extrapolate medication errors
as a patient quality and patient safety indicator. Moreover, the paper will move ahead to utilize
medication errors as a yardstick of solving a clinical problem; depression through 3 small-scale
PDSA quality cycles in a healthcare facility setting.

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 3
Patient Safety Indicators: Medication Errors
Despite the commendable work healthcare institutions do in improving the health care
outcomes of patients across the globe, there has been growing concerns as to whether the care is
given meet the patient's minimum safety and quality standards (Sammer, Lykens, Singh, Mains,
& Lackan, 2010). When patients seek healthcare in healthcare facilities, they do in the
expectation that their health care conditions will be eliminated and possibly completely cured.
However, this is not always the case. Most are the times when patients and patients’ families will
raise complaints against the medication they are accorded, the procedures of medication, and
how they are handled by healthcare practitioners. As such, patient quality and patient safety
indicators are very critical at monitoring and evaluating patient healthcare outcomes and safety
to ensure that patients receive safe and quality healthcare.
For countries under the Organization for Economic Co-operation and Development
(OECD), a comparable and formidable patient safety and quality indicator framework have been
advanced to aid these countries to monitor and evaluate the same at their respective healthcare
systems (McLoughlin, et al., 2006). In their findings, McLoughlin, et al., (2006) included
medication errors to be one of the most critical patient safety concerns and indeed posits as a
formidable patient quality and safety indicator. Medication errors occur at the medication
ordering and administration phase of patient care. These errors have been showcased by
empirical research to advance adverse health outcomes to patients. To this end, this paper will
extensively discuss medication errors as a patient safety concern by way of defining it and
extrapolating how it can be used to evaluate care in a given healthcare setting. Moreover, the
paper will move ahead to utilize medication errors as a yardstick of solving a clinical problem;
depression through 3 small-scale PDSA quality cycles in a healthcare facility setting.

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 4
Medication Error Measurement as a Patient Safety Indicator
According to the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) medication error is under sentinel events category classification. Sentinel events are
medical events that ought not to happen (McLoughlin, et al., 2006). To this end, medication
errors as a patient safety indicator have a numerator that is composed of facets such as the
number of patient deaths, coma, paralysis, and functionality loss. Due to the sentinel event
aspect, medication errors do not have and applicable denominator. However, if in case
medication error is applied to a healthcare facility setting, a suitable denominator should be
utilized to help relate rates between different states or healthcare facilities (McLoughlin, et al.,
2006).
Medication Error Definition
Although clinical therapeutics has had remarkable healthcare outcomes for patients with
different diseases, an increment in risks such as medication error has accompanied these benefits.
There is no precise definition of medication error. However, Lisby, Nielsen, Brock, Mainz
(2010) found 26 varying definitions of medication error in a literature review. Aronson, (2009)
define medication error as an error that can either be of commission or omission that takes place
at any stage along the patient’s medication pathway. The United States National Coordinating
Council for Medication Error Reporting and Prevention [2018] describe a medication error as:
“Any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in the control of the health
care professional, patient, or consumer. Such events may be related to
professional practice, health care products, procedures, and systems,
including prescribing, order communication, product labeling, packaging,

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 5
and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use”
This medication error defination is rather broad but suggests that medication errors are
indeed preventable at various levels in the provision of both primary and secondary healthcare.
The patient's medication pathway normally starts off when clinicians prescribe medication and
stop when medication is actually received by the patient. In case patients are prescribed
medications wrongly, they are likely to suffer preventable adverse drug event (ADE). ADE is the
harm patients undergo though as a result of being exposed to wrong medication such as drug
reactions, poor quality of life, drug-drug interaction, and declined efficacy (Alexopoulou, et al.,
2008).
Medication Errors Classification and Implications
Garrouste-Orgeas, et al., (2012) points out that several approaches are used to classify
medication errors, one of them being classification based on the stage of the patient’s medication
pathway such as dispensing, prescribing, transcribing, monitoring and administration. Secondly,
medication error can be classified by according to the types of medication errors that happen.
These include incorrect medication, administration route, prescription, and frequency. Thirdly,
medication errors can be classified according to whether medication errors happen from mistakes
done during planning such as rule-based mistakes as well as errors committed during the
implementation of well-strategized procedures such as memory-based errors and action-based
errors.
From these classifications, it is vivid that medication errors constitute a formidable
indicator for both patient quality and patient safety outcomes in a healthcare facility setting.
Moreover, medication errors cut across the medical procedure processes and significantly

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 6
influence ultimate patient outcomes. As a patient quality indicator, it exposes the competence as
well as the incompetence of healthcare practitioners in the execution of their healthcare practice
with regard to medication general administration [Agency for Healthcare Research and Quality,
2018].
Medication Errors: Literature Review
Inch, Watson, Anakwe-Umeh (2012) observe that medication errors estimation and
measurement as a patient safety indicator is quite a challenging task because of the different
definitions as well as classifications systems employed by different healthcare systems. In most
cases, the denominator used such as specific medication, patient or prescription is responsible for
the different rates obtained. Moreover, this challenge is compounded by there being extensive
deviations of healthcare systems used by different healthcare organizations as well as there being
different incident reporting systems. These concerns are manifested through different error
prevalence rates reported across the globe. [World Health Organization; Medication Errors,
2018]
In the United Kingdom, for instance, an empirical research established that 12% of
patients receiving primary care have a likelihood of being impacted by either monitoring or
prescribing medication error during any given year. Older persons of 75 years and above are
worst hit as this rate as it rises to 38% while for patients taking 5 or more drugs in any given year
the rate is 30% (Avery, et al., 2012). In yet another study in Sweden, medication error rate was
established to be 42% with two-thirds of the reported cases being related to failures of healthcare
practitioners to indicate treatment objective and purpose on prescriptions. In the same study, 1 %
of medical errors were related to incorrect dose (Claesson, Burman, Nilsson, Vinge, 2008).

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 7
In an investigation of Saudi Arabia’s medication error rate, Khoja, et al., (2011) found
out that at least one-fifth of patients under primary care received medication with massive
prescription errors even though few prescriptions were found to be of an alarming nature. In
Mexico, a study by Zavaleta-Bustos, Castro-Pastrana, Reyes-Hernández, López-Luna, and
Bermúdez-Camps, (2008) noted that 58% of medication prescriptions had errors in which case
dosage regimen was found to be the most prevalent at 27.6%. Garfield, Barber, Walley, Willson,
and Eliasson (2009) in a systematic review assessed medication error rates by categorizing
medication usage processes in which case the study established medication error rate of 3%
during dispensing while failure to make reviews for repeat medications stood at 72% of all cases.
The study also established there were challenges with primary and secondary care integration
with 77% medication error rate reported for outpatient recommendations to general healthcare
providers while discrepancies during discharge stood at 43% to 60% of medication substances
vividly signifying huddles at care transitioning
Causes of Medication Errors
Medication errors are associated with several factors. While examining the patient
reported medication errors in seven countries in a survey, the Commonwealth Fund International
Health Policy established that 11% of primary care patients experiencing the same risk factors
included factors such as poor care coordination, multimorbidity, cost barriers, and hospitalization
(Lu, & Roughead, 2011). Bourgeois, Shannon, Valim, Mandl (2010) assert that medication
errors emanate from increasing number of medication a patient is subjected in, ages of patients
with older persons and children being the most affected, prescription of specific medications
targeting particular healthcare conditions. By and large, Smeulers, et al., 2015) observe that

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 8
different healthcare stakeholders, healthcare workplace environment and different medications
nature contribute to medication errors through different ways.
Potential Solutions to Medication Errors
Although a number of empirical studies have tried to explore ways and means of
improving quality of prescription, most studies’ outcomes are not diverse and medication errors
have actually attracted the attention of few studies (Fanikos, Jenkins, Piazza, Connors, &
Goldhaber, 2014). Medication reviews and reconciliation is one strategy that can be used to
improve patient safety with regard to medication errors. Medication review is interested in
patient's medical evaluation for purposes of elevating patient's health outcomes besides
mitigating adverse medication errors. On the other hand medication reconciliation is concerned
with the documentation of definitive list of medicine through care transitions and going ahead to
rectify discrepancies [Pharmaceutical Care Network Europe, 2016]. Automation of the
medication administration process, healthcare education and training of best practices and
prioritizing critical areas can go a long way in minimizing medication errors and subsequently
elevating the patient quality and safety outcomes.
PDSA quality cycles
The Plan-Do-Study-Act (PDSA) quality cycles structure has been showcased to be very
instrumental in advancing improvement in most patients’ quality and safety healthcare indicators
(Varkey, et al., 2009). Healthcare quality improvement constitutes an extensive range of tasks
and activities with different levels of complexity, statistical and methodological rigor that
healthcare practitioners use to structure, utilize and evaluate small-scale interventions.
Healthcare practitioners then pinpoint interventions that promise optimal outcomes and replicate
them more extensively with the view of improving clinical practice. Patient quality and safety

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 9
outcomes are by and large concerned with advancing healthcare that is more safe, effective and
patient-centered. To register change and improvement in the patient quality and safety, the
PDSA cycle demands healthcare practitioners to ask three questions that inform the improvement
process: What are we trying to accomplish? How will we know that a change is an
improvement? What changes can we make that will result in an improvement? By combining the
three questions with the PDSA cycle a model of improvement emerges (Curnock, Ferguson,
McKay, & Bowie, 2012).
The Improvement Guide, API, 2009.
Solving Medication Error through Small-Scale PDSA quality cycles for Depression Patients

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 10
Medication errors through the wrong prescription, dosage, frequency are bound to
adversely impact depression patients especially because of their mental illness condition and lack
of adequate experience and expertise on mental illnesses by most healthcare practitioners and
these factors by extension compromise on patient quality and safety standards.
Fundamental Questions
What are we trying to
accomplish?
1. Minimize medication errors amongst depressed patients by at least
50% of all reported cases within a period of the next one year by
improving medication handling protocols and procedures.
2. Extensively engage all healthcare stakeholders in quality
improvement approaches related to medication error minimization
3. Improving the health facility environment by removing disruptions
that contribute to depression medication errors
How will we know that
a change is an
improvement?
1. Medication error has been minimized across the entire healthcare
facility with all tasks and activities involved in medication handling
and administration improved
2. Healthcare stakeholders including healthcare practitioners
demonstrate skilled medication management and administration
3. There are proper communication channels and proper drug
arrangements
What changes can we
make that will result in
an improvement?
1. Tighten medication handling protocols and procedures including
medication orders, storage, transcribing, prescribing, dispensation,
and administration.
2. Healthcare practitioners’ training and education on the impact of

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 11
medication errors on patient safety outcomes.
3. Improve and promote open communication and arranging
medication according to their classifications
PDSA quality cycles
PDSA CYCLE 1 Objective: Minimization medication errors by at least 70% of all
previously reported cases
Plan The Improvement being
sought
Minimize medication errors
amongst depressed patients by
Carry out the plan
Collect data
Analyse data
Complete data analysis
Summarize what was learned
Change or test
Define objectives,questions and
indicators
Plan data collection
Plan for the next cycle and
decide whether change will be
replicated
Act Plan
DoStudy

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 12
at least 70% of all previously
reported cases within a period
of the next one year
Time planning Have a hospital Time Planner
Template
Measure of patient safety and
quality indicators
Percentage of reduced medical
errors as indicated by reduced
number of patients and
families reporting wrong
medication prescription
Select change Tighten depression medication
handling protocols and
procedures
Do Implement change Ensure proper protocols and
procedures in medication
handling processes through
proper ordering, transcribing,
proper documentation and
labeling and prescription
administration
Study Evaluate change Process: Improved depression
medication handling protocols
and procedures
Outcome: Number of patients
reporting right medication
outcomes
Act Adopt, reject or modify the
change plan
Positive improvement as
evidenced by reduced
depression medication errors
by 50% of previous reported
incidences.
Increased number of patients
and families reporting right
medication prescription
PDSA CYCLE 2 Objective: Improve healthcare practitioners’ skills and expertise to
minimize medication error by 80% of previously reported cases
Plan The Improvement being
sought
Improve healthcare
practitioners’ skills and
expertise to minimize
medication error by 80% of
previously reported cases

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 13
Time planning Have a hospital Time Planner
Template
Measure of patient safety and
quality indicators
% of reduced medical errors
as indicated by reduced
number of patients and
families reporting wrong
medication prescription
Select change Proper patient healthcare
condition diagnosis to
properly inform correct
prescription.
Healthcare practitioners’
training and education on the
impact of medication errors on
patient safety outcomes.
Do Implement change Tighten patient treatment
procedures
Train and educate healthcare
practitioners
Study Evaluate change Process: Improved patient
diagnosis
Outcome: Number of
healthcare practitioners that
can properly prescribe
depression medications
leading to reduced medication
error
Act Adopt, reject or modify the
change plan
Positive improvement as
evidenced by reduced
depression medication errors
by 60% of previous reported
incidences.
Increased number of patients
and families reporting right
medication prescription
PDSA CYCLE 3 Objective: Improving the health facility environment by removing
disruptions that contribute to depression medication errors and minimizing the same by at
least 90% of all previously reported cases
Plan The Improvement being
sought
Improving the health facility
environment by removing

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 14
disruptions that contribute to
depression medication errors
and minimizing the same by at
least 90% of all previously
reported cases within a period
of the next one year
Time planning Have a hospital Time Planner
Template
Measure of patient safety and
quality indicators
% of reduced medical errors
as indicated by reduced
number of patients and
families reporting wrong
medication prescription
Select change Establish effective
communication channels for
healthcare staff handling
depression patients’
medication.
Do Implement change Facilitate open communication
between healthcare
practitioners and a conducive
working environment free
from disruptions.
Study Evaluate change Process: Improved medication
communication protocols and
procedures
Outcome: Number of patients
reporting right medication
outcomes
Act Adopt, reject or modify the
change plan
Positive improvement as
evidenced by reduced
depression medication errors
by 70% of previous reported
incidences.
Increased number of patients
and families reporting right
medication prescription
Conclusion
Indeed, patient quality and patient safety are critical at in holding the medical profession
accountable by way of demanding healthcare stakeholders meet minimum patient safety and
quality standards. When patients seek healthcare in healthcare facilities, they do in the

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 15
expectation that their health care conditions will be eliminated and possibly completely cured.
However, medication concerns such as medication errors have continuously acted to curtail the
attainment of quality patient outcomes. With proper healthcare facility medication
administration, these errors are not bound to occur. Moreover, healthcare facilities ought to draw
from the potential of PDSA quality cycles hold to inform improvements in medication
administration to minimize medication errors.

PATIENT SAFETY INDICATORS: MEDICATION ERRORS 16
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