Medication Safety: Factors, Consequences, and Strategies for Prevention

Written report: Medication Safety
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Introduction
Provide background information on medication errors, significance of the problem.
Australian Commission on Safety and Quality in Healthcare (2017) suggested that
2% to 3% of discrepancies regarding hospital admissions are related to medication errors.
They also revealed that 230,000 of total admissions in Australia are due to consuming
excessive medicine or wrong medicine. World Health Organisation developed the Patient
Safety Challenge to prevent medication related discrepancies. Parri, Barriball and White
(2015) analysed patient difficulties and the factors contributing to medication error of
registered nurses. This assignment will focus on discussing certain factors leading to the
medication discrepancy, potential consequences, significance to nursing practice and role of
nurses.
Body
Identify three factors that cause medication errors and discuss why these factors lead to medication errors and
impact on patient safety.
Factor One
A very common error that happens during administration of medicines is prescribing error.
The wrong dosage of medicine is often prescribed to patients, or, drugs are selected without
considering the allergy profile of the patient. Mira et al. (2015) revealed that dosage errors is
a very common problem of medication worldwide, with instances of wrong dose calculation
in cancer chemotherapy drugs (calculated with previous weight of the patient) that negated
the effect of the drugs, and dose of carboplatin replaced with cisplatin dose resulting in
severe toxicity. Johnson, Haskell and Barach (2015) reported multiple deaths have occurred
in medical history due to not considering patient’s allergy to anaesthetic drugs. Australia has
the leading cause of death in the world due to anaphylaxis, the most of which are due to
medication. There had been 324 deaths due to anaphylaxis between 1997-2013, 52 of
which are due to medication. It is reported that they have the highest documented hospital
anaphylaxis admission in the world.
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Factor Two
According to Bogner (2018) another cause of medication error that can be considered, is the
incorrect time and the wrong route of administration of the drug. It includes using improper
administration technique to deliver a drug or skipping a dose. Skipping a dose can be
explained as administering the drug at an incorrect time or by means of an incorrect and
inappropriate route. Administering drugs via wring route can drastically impact the patient in
a number of ways such as clogging the blood vessels or acting against the desirable impact
of the medication which would subsequently delay the recovery process. In addition to this,
administering the medication at wrong timings can elicit a cascade of complex chemical
reactions that can interfere with the normal functioning of the physiological functions. Also,
skipping dose of certain medications can overall cease the activity of the medication.
Discontinuation of consumption of antibiotics after recovery, and not completing the
prescribed course, can invalidate the effect of others. Martinez-Ramirez et al. (2015)
suggested that missing dopaminergic dosage of drugs in hospitalized patients of Parkinson’s
disease prolonged their duration of stay in the hospital. It should be noted in this regard that
certain dosage of solid oral medication while administering to patients with limited ability to
consume the drug orally are crushed and administered intravenously. It should be noted that
crushing and or dissolving solid oral tablets lead to destruction of protective enteric covering
of the release medications and might reverse the intended therapeutic action. One instance
where wrong route of medication led to death of a patient can be explained as the case of 97
year old, Nymphea Anderson who was administered a mixture of 3 crushed oral tablets that
was intravenously administered to her by a nurse (Bibby 2019).
Factor Three
Paranad et al. (2016) suggested that another factor that contributes to medication error can
be explained as incorrect dose preparation of the drug or committing an error with the
preparation of ‘Look alike sound alike’ medication. Look alike sound alike medication or
LASA medication create confusion among care professionals which lead to fatal health
outcome within a healthcare environment. In this regard, it should be noted that medicines
that are packaged in an identical way constitute the ‘look alike’ medication and the drugs
whose generic name are similar are referred to as the ‘sound alike’ medication. Research
studies reveal that LASA drugs can be used interchangeably and could lead to adverse
patient outcome (Rash-Foanio et al. 2017). Research reports reveal that on an average 15%
of the medication errors occur on account of incorrect medication preparation pertaining to
human error as caused due to the interchangeable use of LASA drugs (World Health
Organization 2017).
Conclusion
Describe how the evidence will inform your practice on clinical placement.
Hayes et el. (2015) suggested that medication administration errors continue to be a potent
patient-safety issue, internationally. His study revealed that a considerable numbers of
medical errors have happened due to interruptions faced during administration or
distractions. A number of research studies have also revealed that insufficient knowledge
about pharmacology also attributes to medication error that concerns incorrect route of
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