Literature Review: Medication Errors and Nursing Practices

This literature review examines the critical issue of medication errors within the nursing field, focusing on their causes, consequences, and potential solutions. The review delves into the Australian healthcare context, highlighting the role of nurses and healthcare centers in ensuring patient safety. It analyzes the factors contributing to medication errors, such as look-alike drugs and distractions, and explores the significance of the National Safety and Quality Health Service (NSQHS) standards, particularly Standard 4: Medication Safety. The review synthesizes findings from various studies, categorizing them into themes like medication errors in healthcare settings, systems for improving medicine administration, and the promotion of multidisciplinary care. It discusses the impact of technology, such as smart infusion pumps, and strategies like Tall Man lettering in reducing errors. The review emphasizes the importance of robust governance, reporting systems, and accurate documentation, while also highlighting the value of multidisciplinary care in enhancing patient safety and improving the quality of healthcare. The review underscores the catastrophic potential of medication errors and the ongoing efforts to mitigate these risks through adherence to established standards and the implementation of innovative practices.

Literature Review:
Nursing

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
BACKGROUND.............................................................................................................................1
LITERATURE REVIEW................................................................................................................2
Medication errors in health care setting in regard to the administration and dispensing of
medicines....................................................................................................................................2
System to improve medicine administration and dispensing......................................................3
Standard 4: Medication and Safety.............................................................................................3
System promoting multidisciplinary care...................................................................................4
DISCUSSION..................................................................................................................................5
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................7

INTRODUCTION
The process of prescribing, dispensing, manufacturing, compounding and monitoring
medicines is critical which involves numerous clinicians. As there are multiple tasks and
interactions occurred in the whole process, the probability of medication errors increases
simultaneously (Hayes, Davidson and Power 2015, pp. 3063-3076). The role and responsibility
of nurses and health care centre is to ensure patient’s safety while providing him or her precise
treatment. Any harm to patient due to medication error can be catastrophic (Jember, Demeke and
Hassen 2018, pp. 9). Importantly, however these errors are often preventable. The best practice
followed by the health care management is to avoid the medication errors. To manage safe and
healthy practices in the health care organisation, The Australian Commission on Safety and
Quality in Health Care (ACSQHC) has developed 10 NSQHS standards. The primary aim of
National Safety and Quality Standards safeguard the people from harm and enhance the quality
of health safety provisions (Hutchinson and et.al. 2015, pp. 70).
These standards concentrate on client’s engagement, governance, clinical related areas and
provide conformable statement of the level of care that health care seekers expect from health
services. The aim of this review is to analyse the factors that causes medication errors and
reviewing Standard 4: Medication Safety in order to get knowledge about how to avoid these
errors efficiently (Debono and et.al. 2017, pp. 42). This will be attained by reviewing the
available literature on these topics. Nurses plays a pivotal role in preventing the errors related to
the administration of medication in hospitals where such type of error is one of the topmost
reason behind injuries to the patients hospitalised in the health care settings. Some major factors
that mainly contributes to the medication administration errors involves drugs looking alike and
distraction where the nurses are mostly tired and exhausted. Also, physicians non-
understandable handwriting leads to such type of errors in medication. However, most of the
cases are not reported due to a fear from supervisors or peer’s adverse reactions, etc.
BACKGROUND
According to Hutchinson and et.al. (2015) medicines are most commonly used
terminology in health sector and it refers to the deviations done from a doctor’s prescribed
instruction. This includes errors like unreadable written prescriptions, errors in dispensing,
calculating, monitoring and administration, etc. It is with a foremost involvement of the nurses
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who are mostly seen in making such type of errors that increases when remains unreported. As a
result, they are one of the major reason for higher incidence of errors and show adverse effects
than other health care interventions. 25 per cent of incidents occurred in public hospital of
Australia were caused by medication errors (Mitchell, Williamson and Molesworth 2016, pp.
185-195). Medication errors can be catastrophic as it can harm patient’s health drastically. The
motive of health care centres is to ensure the safety of health care seekers. According to Mitchell,
Williamson and Molesworth (2015) in order to improve the health and safety practices in
Australia, the Australian Commission on Safety and Quality in Health Care (ACSQHC) has
formulated National Safety and Quality Standards which aim to ensure the protection and
preservation of patient and improve quality of health and safety provisions.
As per Debono and et.al. (2017) the quality framework possesses 10 standards each of
which focuses on improving the quality of health and safety, clinical process and provisions.
Standard 4 which is Medication Safety intends to make sure that clinicians safely prescribe,
dispense and administer appropriate medicines to inform the patients and carers (Heneka and
et.al. 2018). There are several policies and procedures formulated by health care services in order
to use medicines in an appropriate and precise manner (Parry, Barriball and While 2015, pp. 403-
420). It is essential to access, comprehend and adhere to systems, policies and procedures
developed by specific health care service centre. The NSQHS Standard 4, 4.2 recommend that
the management of health care centre needs to innovate effective strategies that help in
administering reduction of medication errors in the health care centre in order to ensure quality
care provided to patients (Mitchell, Williamson and Molesworth 2015, pp. 163-174).
LITERATURE REVIEW
In literature review, numerous studies were analysed which are relevant to the subject
matter. All the findings were categorised into different themes which help readers to comprehend
each aspect effectively and efficiently. These themes are medication errors in the health care
setting, system to improve medicine administration and dispensing, Standard 4: Medication and
safety and system promoting multidisciplinary care.
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Medication errors in health care setting in regard to the administration and dispensing of
medicines
According to Heneka and et.al. (2018) medication errors can be disastrous and may harm
both; the patient and nurses. In order to prevent medication errors in the health care organisation,
it is very important for management to formulate precise strategies and plans which can assist
care providers efficiently and reduces medication errors. Jember, Demeke and Hassen (2018)
said that administration errors broadly define as any error in the prescribing, dispensing or
administration of drugs. The end result is catastrophic as patient has to suffer a lot after wrong
medication provided to him. In the direct observational study conducted in six medical wards in
two major hospitals of NSW, it was identified that over 80 per cent medicine administration were
related with either procedural or clinical errors.
Williamson and Molesworth (2016) contends that medication errors can be in many
forms such as procedural, clinical, time, dosage amount, etc. In order to improve the health and
safety practices in health care centre, it is important for the management to identify the loopholes
and formulate precise policies and norms in order to obliterate them efficiently. Parry, Barriball
and While (2015) argued that medication errors can be occurred through inappropriate
dispensing of medicines and distribution and storage of medications. Wrong disposition of
medicines and storing medicines inappropriate place might lead to catastrophic situations.
System to improve medicine administration and dispensing
Nesbitt, Levett-Jones and Gilligan (2018) said that in today's era technologies are
evolving rapidly and health care organisations are greatly boon by these technologies. The
advance technologies result in declining the rate of errors in hospitals and enhances the quality of
care efficiently. Intravenous (IV) errors can be disastrous for patient health. In order to obliterate
it the management must utilise smart infusion pumps so that the possibilities of occurrence of
errors can be reduced drastically (Garrett and McCormack, 2014, pp. 29-34). According to
Alqubaisi, Strath and Stewart (2016, pp. 1401-1411) 432 infusions were audited in Melbourne
hospital in the pre intervention period and 266 in post intervention period. During post
intervention period 60 per cent infusion were administered by utilising Guardrails software. It
was identified that 18 per cent of infusion has one or more errors, the error rates were
significantly lower after interventions of smart infusion pumps (Nesbitt, Levett-Jones and
Gilligan 2018).
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Thus, it implied that resourcing smart infusion pump lowers the rate of infusions error
effectively and efficiently. Carnes (2015) said that Tall Man lettering strategy tends to be useful
in order to eliminate medication errors regarding name of medicines. The strategy was proposed
to reduce confusion with the name of medicines or medicines that looks alike. Two studies were
conducted in year 2008 that investigates the use of Tall Man lettering in hospitals of Australia
(Vaismoradi Turunen and Jordan, 2016, pp. 970- 980). One was laboratory based study which
investigated the rate of errors identified due to confusion between medicines names. The study
does not found any significant type of differences in errors. Another study was conducted in
hospital network in Victoria (Alqubaisi, Strath and Stewart 2016). Labels using Tall Man
lettering were added to clinical shelves and ward medicine storage areas and Tall Man lettering
was introduced into the pharmacy dispensing software.
Standard 4: Medication and Safety
According to Byrne and Bury (2018) the National Safety and Quality Health Service
Standards formulated by the Australian Commission on Safety and Quality in order to enhance
the safety and protection of the patient and improve the quality of health and safety provisions,
policies and procedures. Kim, Mazan and Quiñones-Boex (2017) said that the role of these
standards is to establish safety and protection to the patient who visited health care organisation
in order for quality treatment. According to Alkatheri and et.al. (2017) standard 4 has been
categories into 15 criteria which provides specific guidelines in order to ensure medication safety
in the health care organisation. These guidelines are mandatory to be followed by health care
centres and hospitals incorporating in Australia. Criteria 4.1 of standard 4 mandates to formulate
robust governance arrangements and organisation policies so that chances of errors can be
reduced adequately.
Alomari and et.al. (2017) argued that criteria 4.4 mandates that management of health
care centres need to use strong organisation wide system of reporting system which can report to
medication incidents. The motive of the framework is to obliterate the possibilities of errors and
provide healthy and safe environment in the health care centre so that patient can have better
health experience. According to Carnes (2015) standard 4.6 mandates the clinical workforce to
record and document the medical history of patient in effective and accurate manner so that
possibilities of occurrence of errors can be reduced effectively and efficiently. In order to
promote healthy and safety practices within the health care centres, it is important for the
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management of health care centres to follow these in precise and efficient manner (Byrne and
Bury 2018, pp. 1-5). Through this they can reduces the chances of errors and promotes health
and safety within the centre.
System promoting multidisciplinary care
Hayes, Davidson and Power (2015) enunciated that multidisciplinary care in health and
social care centre are very important and essential. By using collaborative home medicines
review in the community setting, the management of health care centre can enhance the quality
of care provided to the patients. Roughead, Semple and Rosenfeld (2016) said that Australian
government make funds for conducting home medicine review which is an initiative in which
accredited pharmacists partnered with GP and regular community pharmacy. The accredited
pharmacists conduct the home review of patients and identifies the type of medicine required and
submit the report to the GP. The GP and patient makes agreement on the plan and medication
(Omura and et.al. 2015, pp. 500-506).
According to Mikhail, Grantham and King (2017) it is the role and responsibility of
nurses and health care centre is to ensure patient safety while providing him or her precise
treatment. Any harm to patient due to medication error can be catastrophic. Importantly, however
these errors are often preventable. The best practice followed by the health care management is
to avoid the medication errors. To manage safe and healthy practices in the health care
organisation. Through multidisciplinary care, the management of health and social care centre
incorporating in Australia is able to enhance the quality of care by reducing the medication
errors.
DISCUSSION
From the analysis of articles, it was identified that medication errors are catastrophic for
patient health and dignity of health care centre. As there are multiple tasks and interactions
occurred in the whole process, the probability of medication errors increases simultaneously. 25
per cent of incidents occurred in public hospital of Australia were caused by medication errors.
Medication errors can be catastrophic as it can harm patient health drastically (Kim, Mazan and
Quiñones-Boex 2017, pp. 201-205). The motive of health care centres is to ensure the safety of
health care seekers. From the studies it was identified that more than 80 per cent medicine
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administration were related with either procedural or clinical errors (Roughead, Semple and
Rosenfeld 2016, pp. 113-122).
These errors occurred due to wrong time, inaccurate dosage, wrong medication etc.
Researchers conducted their studies in hospitals located in New South Wales, Australia. It was
also identified that using advance technologies, the management would be able to reduce the
chances of errors. In the study conducted in hospitals, it was identified that using Smart infusion
pumps during infusion (IV) process, 18 per cent reduction in the errors has been observed. The
Standard 4 of NSQHS have 15 criteria which are to be followed by the health care centre in order
to ensure maximum safety and protection of patients (Alkatheri and et.al., 2017, pp. 30; Alomari
and et.al., 2017, pp. 1-17). By using collaborative practices as a multidisciplinary approach, the
management can improve safety practices and eliminating medication errors.
CONCLUSION
From the above study, it can be concluded that medication errors are catastrophic for
human health. Study concentrates on the aspects of medication safety and errors policies as well
as procedures which are meant to be followed by the health care centres. In this context, the
researcher has analysed the standards formulated by Australian Commission on Safety and
Quality in Health Care. The standard 4 of NSQHS focuses on the medication safety which are
mandatory to be followed by the health care centres. The literature review highlighted that there
are majority of medication errors occurred either due to procedural and clinical errors. These
include time errors and dosage errors. Furthermore, it was identified that there are 15 criteria in
the Standard 4 of NSQHS. Each criteria provides guidelines through which quality of care can be
enhanced. Eventually, through collaborative approach, the medication error can be reduced
effectively.
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REFERENCES
Books and Journals
Alkatheri, A. M., & et.al. (2017). Pharmacy Educators’ Knowledge of Medication Safety and
Their Perception Toward Its Integration into the Doctor of Pharmacy Curriculum in Saudi
Arabia. American journal of pharmaceutical education. 81(2). 30. doi:
http://www.tandfonline.com/doi/abs/10.1080/24694193.2017.1323977
Alomari, A., & et.al. (2017). Pediatric Nurses’ Perceptions of Medication Safety and Medication
Error: A Mixed Methods Study. Comprehensive child and adolescent nursing. 1-17. doi:
http://www.tandfonline.com/doi/abs/10.1080/24694193.2017.1323977
Alqubaisi, M., Strath, A., & Stewart, D. (2016). Quantifying behavioural determinants relating to
health professional reporting of medication errors: a cross-sectional survey using the
Theoretical Domains Framework. European journal of clinical pharmacology. 72(11).
1401-1411. doi: https://link.springer.com/article/10.1007/s00228-016-2124-z
Byrne, E., & Bury, G. (2018). Barriers to the medication error reporting process within the Irish
National Ambulance Service, a focus group study. Irish Journal of Medical Science
(1971). 1-5. doi: https://link.springer.com/article/10.1007/s11845-018-1745-x
Carnes, D. M. (2015). Getting the truth: a qualitative comparative analysis of rural nurses'
attitude to safety climate and their views of reporting a hypothetical medication error
(Doctoral dissertation, University of Tasmania). doi: https://eprints.utas.edu.au/23158/
Debono, D., & et.al. (2017). Applying the Theoretical Domains Framework to identify barriers
and targeted interventions to enhance nurses’ use of electronic medication management
systems in two Australian hospitals. Implementation Science. 12(1). 42. doi:
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-017-0572-1
Garrett, T., & McCormack, C. (2014). Does an electronic discharge referral system improve the
quality of medication prescribing?. Journal of pharmacy practice and research. 44(1). 29-
34. doi: http://onlinelibrary.wiley.com/doi/10.1002/j.2055-2335.2014.tb00013.x/full
Hayes, C., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: a literature
review of disruptions to nursing practice during medication administration. Journal of
clinical nursing. 24(21-22). 3063-3076. doi:
http://onlinelibrary.wiley.com/doi/10.1111/jocn.12944/full
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Heneka, N., & et.al. (2018). Exploring Factors Contributing to Medication Errors with Opioids in
Australian Specialist Palliative Care Inpatient Services: A Multi-Incident Analysis. Journal
of palliative medicine. doi: https://www.liebertpub.com/doi/abs/10.1089/jpm.2017.0578
Hutchinson, A. M., & et.al. (2015). Implementation of an audit with feedback knowledge
translation intervention to promote medication error reporting in health care: a
protocol. Implementation Science. 10(1). 70. doi:
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0260-y
Jember, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and
associated factors among nurses: a cross sectional study. BMC nursing. 17(1). 9. doi:
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-018-0280-4
Kim, C., Mazan, J. L., & Quiñones-Boex, A. C. (2017). Comparison of community and hospital
pharmacists' attitudes and behaviors on medication error disclosure to the patient: A pilot
study. Journal of the American Pharmacists Association. 57(2). 201-
205.http://www.japha.org/article/S1544-3191(16)30866-4/abstract
Mikhail, J., Grantham, H., & King, L. (2017). Do User-Applied Safety Labels on Medication
Syringes Reduce the Incidence of Medication Errors During Rapid Medical Response
Intervention for Deteriorating Patients on Wards? A Systematic Search and
Review. Journal of patient safety. doi: http://europepmc.org/abstract/med/28872476
Mitchell, R. J., Williamson, A., & Molesworth, B. (2015). Use of a human factors classification
framework to identify causal factors for medication and medical device-related adverse
clinical incidents. Safety science. 79. 163-174. doi:
https://www.sciencedirect.com/science/article/pii/S0925753515001447
Mitchell, R. J., Williamson, A., & Molesworth, B. (2016). Application of a human factors
classification framework for patient safety to identify precursor and contributing factors to
adverse clinical incidents in hospital. Applied ergonomics. 52. 185-195. doi:
https://www.sciencedirect.com/science/article/pii/S0003687015300478
Nesbitt, K., Levett-Jones, T., & Gilligan, C. (2018). Safe dispensing in community pharmacies:
applying the software, hardware, environment and liveware (SHELL) model. Stroke. 13.
57. doi: http://www.pharmaceutical-journal.com/research/safe-dispensing-in-community-
pharmacies-applying-the-software-hardware-environment-and-liveware-shell-model/
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Omura, M., & et.al. (2015). Measuring the impact of an interprofessional multimedia learning
resource on Japanese nurses and nursing students using the Theory of Planned Behavior
Medication Safety Questionnaire. Nursing & health sciences. 17(4). 500-506. doi:
http://onlinelibrary.wiley.com/doi/10.1111/nhs.12224/full
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medication administration error: A narrative review. International journal of nursing
studies. 52(1). 403-420. doi: http://www.journalofnursingstudies.com/article/S0020-
7489(14)00173-4/abstract
Roughead, E. E., Semple, S. J., & Rosenfeld, E. (2016). The extent of medication errors and
adverse drug reactions throughout the patient journey in acute care in
Australia. International journal of evidence-based healthcare. 14(3: Medication Safety
Issue), 113-122. doi:
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d_adverse_drug.3.aspx
Vaismoradi, M., Turunen, H., & Jordan, S. (2016). Transformational leadership in nursing and
medication safety education: a discussion paper. Journal of nursing management. 24(7).
970-980. doi: http://onlinelibrary.wiley.com/doi/10.1111/jonm.12387/full
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