Medication Error: Factors, Strategies, and Outcomes

This report delves into the critical issue of medication errors within the healthcare sector, highlighting its detrimental impact on patient health outcomes. The analysis identifies lack of knowledge and training among nurses, ineffective communication between healthcare professionals, and excessive workloads as primary contributors to these errors. The report emphasizes the importance of strategies such as medication reviews, the implementation of computerized provider order entry (CPOE) systems, and the 'read-back' method to prevent errors. The findings underscore the need for evidence-based practices to improve patient safety and inform clinical decision-making, stressing the significance of continuous improvement in nursing practice through dose calculation, drug administration, and effective communication to enhance patient outcomes and reduce adverse events.

Running head: MEDICATION ERROR
MEDICATION ERROR
Name of Student:
Name of University:
Author’s Note:

1MEDICATION ERROR
Medication error is the most concern issue in the health care sector that has deteriorated
the health outcome of the patient. It has significant implication on the safety of patient. It is
defined as any preventable error that can cause harm to patient due to inappropriate use of
medication. The error can place the initial period of drug prescriptions to the administration. It
has contributed high mortality rate in health care sector (National Safety and Quality Health
Service Standards 2019). Therefore, the main aim of the paper is to discuss about the major
factor that has led to medication error and key strategies that could be taken to prevent it and
improve the health outcome of the patient. The three factors that has cause medication errors are
described as follow:
Lack of understanding and knowledge among the nurses is One of the main cause of
medication error is lack of proper drug knowledge, experience and therapeutic training by nurse
regarding medicine safety guideline. Several studies have reported to show that for medication
error can occur in while prescribing, dispensing, administration, packing and distribution of
medicine (Australian Commission on Safety and Quality in health Care 2019). According to the
role of nurse, they are legalised to administer the medicine, for which they need to have
adequate information about the different types of medicine, dose calculation, route of
administration and frequency of intake of medicine. It is reported, if the nurse are efficient in
above-mentioned areas, can lead to lethal consequence in the health of the patient (Palese et al.
2015). Wrong administration of drugs can deteriorate the health condition of patient and risk the
safety of patient.
Medication error can also occur when there is lack of effective communication between
the doctors and nurse, or between nurse and patient. It is reported that often the nurse due to
similar names, use of acronyms, unclear prescription and telecommunication prescription drugs,

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misinterprets the prescribed medicines. Nurse fails to understand the accurate drug and dose size,
which can result in wrong drug administration in the patient. As the consequence of such issue,
the patient may show negative impact and allergic reactions and even lead to risk regarding
safety of patient as reported in the book of Berman, Snyder and Frandsen (2016). Sometime,
nurse fails to acquire medication history from the patient, which can be due to poor
communication and result in administration of wrong medicines.
Other contributing factors that has raised the incidence of medication error is concerned
with workload of nurse. There is growing evidence that heavy workload in the nursing team is
linked with patient safety. From the book by Berman et al. (2017) it was analyses that they are
unable to effectively work and surveillance the patient safety and end up giving wrong
medication. They are unable to pay attention to medication chart of the patient, investigate the
patient about the medicine allergy. It is reported in the study of Faisy et al. (2016) that due to
busy schedule of nurses, they fail to document the medication prescribed which create gap in
knowledge during clinical handover of the case of the patient. Such also results in poor
communication between and cause misinterpretation of right medicine. It has potential negative
impact on the health of the patient, which increase hospital stay or re-admissions.
From the above evidence and discussion, it can be concluded that medication error is
mostly prevalent due to lack of evidence-based practice. It has given me insight about the
medication error and major areas, which can contribute to adverse health outcome of the patient.
Through the evidence collected, I will take important measures to improve my practice and will
focus on ways to lower the incidence of medication error. I can apply this evidence in clinical
placement by being conscious in dose calculation, drug administrations, documenting the

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medication history of the patient. It has also inform the significance of effective communication
between doctor and nurse, which I can implement in my nursing practice.
The key strategies that can be taken to prevent medication error are as follow firstly, The process
of medication review involves evaluation of the medicine prescribe to the patient with objective
to provide quality care and mitigate drug related issue. It is evident from the study of Mekonnen
McLachlan and Jo-anne (2016), where author a conducted systematic review of 38 studies based
on care intervention in order to lower the medication error and found that the most relevant
intervention to was medication review done by pharmacist and nurses. The reconciliation of
medication is referred as active documentation of the definitive list of medication during the shift
of care. There is the need to make a clear report of the medicine by the nurse being prescribe by
the doctors. It is help in reduction of medical error due to lack of awareness about the history of
patient (Cloete 2015).
Secondly, The strategy of use of the computerized provider order entry (CPOE) with
support of decision of the health professional can be effective in preventing medication error due
to poor communication. The strategy has been proved to be effective by study of Padmani et al.
(2016) where author has considered RCT based article and evaluated that CPOE has been
effective in improving the health outcome of the patient. All the information regarding the
dispensing, transcribing, prescribing, dose size, route of administration and time period of
consuming the medicine should be recorded and stored in the computer as medication
administration record (MAR). The active action needs to be performed at all level of treatment
plan, that includes at pharmacy, nursing intervention and doctor’s appointment.
Thirdly, The process of reading back the prescribe drug by the nurse to the physician in
order to ensure the right medication. The nurse can use the strategy at the time of transcribing of

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the patient, which is mentioned in the book by Levett-Jone and Bourgeois (2010). The strategy
needs to be carried out by the one nurse to other nurse and read back the ordered medicine
(Vogelsmeier et al. 2017). It will help to prevent medication error by the nurse and physicians.

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Reference
Australian Commission on Safety and Quality in health Care . 2019. Medication Safety Standard
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https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard
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