Patient Safety Indicators: Medication Errors

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,