Nursing Practice Capstone (NPP6105): A Report on Medication Errors

This report delves into the critical issue of medication errors within nursing practice, examining its multifaceted nature and implications. It begins by defining medication errors and their potential for causing patient harm, then explores both medical and managerial factors that contribute to their occurrence. The report analyzes the impact of these errors on patient health, including physical and mental consequences, and also discusses the emotional toll on nursing staff. It further investigates related aspects such as clinical leadership, teamwork, and legal/ethical considerations, offering recommendations for preventing future incidents. The role of a registered nurse in error detection, prevention, and patient care is also highlighted, emphasizing strategies like medication reconciliation and documentation. The report concludes by underscoring the importance of continuous learning and proactive measures to ensure patient safety and improve nursing practice.

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NURSING PRACTICE CAPSTONE Date 30.08.2019

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Nursing profession demands high care and skills as it directly affects the health of
patients. In day-to-day healthcare practice, many of the issues have been reported in context of
nursing which are known as clinical nursing issues. Such issues are highly significant to be
understood as they have dangerous and long-term consequences in general. The issue selected
for this report is medication error. In the presented report, an overview of the issue will be
discussed. A further focus will also be developed on the factors that contribute to the issue and
the manner in which selected issue affect the patient and the nursing team. In conjunction with
this, some recommendations to eliminate this issue will also be discussed. The objective of the
report is to develop a deep understanding of medication error and to check how this learning
informs the role of a registered nurse.
A medication error is a preventable event that may lead to inappropriate use of
medication or may cause harm to a patient while the medication is in the control of healthcare
professional or patient (Nccmerp.org, 2019a). Such events may be related to healthcare products,
order communication, professional practice, product labeling, nomenclature, packaging,
distribution, monitoring, compounding, and use. Such error increases the risk of harm in respect
to consumption of medicines. In different parts of the world, the rate of medication error is
differentiated due to various circumstances. For instance in the UK around 5% of prescriptions
used to have errors. On the different side, as per a Swedish study, the said error rate is 42%
(Apps, 2019). If to discuss the reasons behind medication error this is to state that there are no
one or two specific reasons but different causes exist and lead to different incidents.
Mainly two types of factors have been noted as a cause of a medication error. One is
medical factors and other is managerial and human factors. Firstly, to discuss medical factors,
this is to state that the same include confusion with respect to administration of medicines. For

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instance, having a variety of drugs in the medicine cabinet. In such a situation, healthcare
professionals pick wrong medicines sometimes that further lead to the issue of medication error.
Similarly many times healthcare professional uses acronyms rather than the complete name of
medicine. Such a situation creates confusion because more than one medicine can have same
acronyms and junior staff can misunderstand one medicine with another. Similarly, sometimes,
the name of two or more medicines seems to be similar which again creates confusion.
Frequency distribution of these factors which lead to the medication errors can be understood by
having a look at the following chart:-

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(Cheragi, Manoocheri, Mohammadnejad, & Ehsan, 2013)
On the other side, managerial and human factors, which contribute to a medication error,
include tiredness due to excessive work, inadequate training of staff, incorrect medicinal
calculations, and other issues; that affect the human abilities. Many of the times, the staff of the
hospital has less knowledge of medicines and therefore they fail to understand the instructions of
healthcare professionals. This again gives rise to a medication error.
A medication error is not a minor issue and has the capacity to lead to serious
consequences. In many of the cases, it has been noted that medication error causes the new
medical condition, either temporary or permanent. Such physical conditions include rashes,
itching or skin disfigurement (Qlicksmart, 2019). This would be wrong to state that such errors
only lead to minor issues but at many times, it also affects the health of patients badly.
Uncommon medication errors may even cause death to the patients. Not only had the physical

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but mental health of patients been affected due to the medications errors. It has been seen that
such errors spread fear among patients and family members with respect to patient safety. Here it
is necessary to understand that the body of every person reacts differently to medication. This is
the reason that before prescribing any medication, healthcare professionals diagnose the patient's
body as any treatment needs to be very specific. In such a situation, any error in treatment or
medication leads to serious consequences to the patient's health and can make his/her situation
even worse.
It would be wrong to state that medication error only affects a patient's health but the
same also lead impact on the members of the nursing team as well. Nurses or other healthcare
professionals, who commit/pursue medication error, may suffer from guilt, shame, or self-doubt
(Hughes, 2008). Even in some of the same cases, nurses have been stated to become the
secondary victims of such medication errors. The result of this syndrome can be life-threatening
for them. In one case, a senior nurse committed suicide when she inadvertently gave 10 times
more calcium chloride to a fragile baby. In this case, the baby was the primary victim of
medication error whereas nurse who committed suicide was secondary victim (Aleccia, 2011).
Member of the nursing team feels embarrassed after the commitment of medication error and in
one of the study it was found that only 3% of healthcare professionals inform their patients
regarding such error. Further doctors may also have to face lawsuits from the side of the patient's
family members that adversely affect their career. Such litigations impose an additional
emotional burden to the nursing practitioners in conjunction with the stress from a medication
error.
There are many aspects, which is closely connected to the medication error. In this part of
the report, the issue will be discussed in regards to these aspects that include clinical leadership,

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teamwork, legal and ethical issues and so on. Firstly, to discuss clinical leadership, this is to state
that it plays an important part in a medication error. Often those organizations where such
leadership is missing faces the issue of medication error. By using appropriate leadership and
management, such cases can be prevented. By using efficient leadership education, knowledge
level of staff with respect to medicines can be enhanced (Vaismoradi, Griffiths, Turunen, &
Jordan, 2016). The second aspect to study is conflict management. Conflict occurs when there
are medication errors and vice versa. Collaboration and coordination between doctors and nurses
decrease the risk of medication errors (Ameen, 2017). The fewer conflicts would be there, the
more satisfaction will be there among nursing staff members. In such a manner, this is not wrong
to state that a proper conflict management system reduces the level of medication errors.
Teamwork also plays a significant role in medication errors. A patient is not the
responsibility of one or more healthcare professional but sometimes the whole nursing team
takes care of one patient. Such incidents requires a great teamwork as a whole. The importance
of teamwork becomes more crucial when it comes to emergency departments. Here healthcare
professionals need to maintain a good level of communication and coordination among them. If
they would not be able to understand each other and will not properly coordinate then there are
high chances of medication errors. As per one of the studies conducted in this area, 8.8 teamwork
failures occur per cases on an average basis that can be prevented by better teamwork (Salas &
Frush, 2012).
Administration and system failure is one of the reasons for medication error. Every staff
member of the nursing team has some responsibilities being delegated and therefore they are
required to work accordingly. Team of healthcare professionals must be aware of their duties
(Nursingworld, 2019). Many of the times, people have no clear understanding of their role and

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therefore they fail to perform their duties on time or end up performing the duties
inappropriately, which lead to a medication error. Hence, a proper delegation of responsibilities
is required to be there. Lastly, the subjective error leads to many legal as well as ethical issues to
healthcare professionals. Out of an incident of a medication error, they may have to face an
allegation of medical negligence. Further, such incidents also put a question mark to the ethics
and morality of such professionals.
Once the medication error has occurred, the next step is to fix the issue. The situation of
medication error can be managed in different ways. Nevertheless only managing this one-time
situation is not enough but efforts are also required to prevent re-occurrence of the same.
Immediate actions and analytical thinking can manage the situation. Here healthcare
professionals must focus on solutions rather than blaming each other for errors as it may defeat
their reputation. They need to analyze the reaction of such error and the manner in which these
health reactions can be addressed. Further, after a medication error, the patient is required to be
kept under surveillance. To manage the situation properly, reporting of the issue as per the policy
of the organization is another thing to do. Under this report, everything related to the case such
as what, who, where, how and when of the event must be documented (Pharmacytimes.com,
2016). This report helps to understand the deviation from the ordinary operating process,
uncover patterns within the data and to understand the manner in which similar incidents can be
stopped in the future.
If to discuss the recommendations regarding prevention of re-occurrence of such events,
proper placement of medicines is recommended. Nursing team members must have knowledge
regarding storage, access, and distribution of medicines. Proper delegation of authority and
responsibility must be there. Further healthcare organizations are advised to arrange education

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and training program for technical support personnel, healthcare professionals, and patients that
address methods for eliminating such errors (Nccmerp, 2019b). Apart from these, safety
strategies may also be developed for preventing re-occurrence of errors.
Apart from the above-mentioned discussion, it is far clear that the issue of medication
error needs significant attention. As a result of this learning experience, the role of the registered
nurse is clear. A registered nurse is required to act as per the terms of her license and has more
responsibility towards a patient in comparison to other nurses. Such nurses play a significant role
in discovering and collection of the medication errors. They are expected to catch such errors and
to prevent them from reaching up to patients. They play an important surveillance role in the
intensive care environment and this role becomes even more crucial when the patient is a
seriously ill person. Further registered nurses are also required to understand the factors behind
subjective errors and the person who were engaged in such errors in the past. As per a study
conducted in the past, nearly 367 errors have been discovered during a period of 28 days.
Individual nurses reported 0 to 12 errors (Rogers, Dean, Hwang, & Scott, 2008). Registered
nurses do not only discover medication errors but in conjunction with this, they also identify
other critical care errors. In addition to the discovery of such errors, registered nurses also have a
role to prevent such errors. They need to act as per instructions of their license and to report the
identified issues to senior authorities. Nurses should consider their responsibility and work
according to the responsibilities delegated to the same. They are required to give drugs
responsibly and to observe the patient's responses. Being a registered nurse, the first strategy for
the reduction of a medication error is to follow a proper reconciliation procedure. The nurses
should review and verify each of the medicines and must ensure that they are giving correct
dosage of correct medicines to the correct patients. Secondly it is imperative to engage into a

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documentation of medication. The documentation practice helps in future references and serves
as a guide to understand behavior of patient towards specific medicines. In conjunction with
these, some other strategies such as usage of drug guide, usage of name alert and double-
checking of procedures must also be used.
Conclusively, this is to state that medication errors lead to serious consequences to the
patients as well as to healthcare professionals and therefore this is a topic of consideration. In the
presented essay, the meaning and lead causes of medication error have been identified.
Generally, such kind of errors seems to be there because of less knowledge of medicines and
miscommunication. Further, such errors adversely affect the patient's health and also lead the
risk of legal proceedings to healthcare professionals. It has been identified that by having
appropriate teamwork, a delegation of authorities and conflict management system, risk of
medication errors can be reduced. As soon as a situation of medication errors occurs, the
responsible person must pay additional attention to the patient and should observe his/her health
over a period. In addition to this, a report summarizing the issue/event must also be submitted to
a higher authority. Lastly, after the whole learning experience, this can be stated that registered
nurses are responsible to check and discover these errors as well as to prevent the same
considering their responsibilities.

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References
Aleccia, J. (2011). Nurse Suicide highlights twin tragedies of medical errors. Retrieved From:
http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-
twin-tragedies-medical-errors/#.XWqnVCgzbIU
Ameen, F. (2017). Nurse-Physician Conflict and Power Dynamic. JOJ Nurse Health Care, 5(3).
Apps. (2019). Medication Errors. Retrieved From:
https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-
eng.pdf;jsessionid=6B95BD352D4828F461AF96A428360EB0?sequence=1
Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes
of medication errors from nurse's viewpoint. Iranian journal of nursing and midwifery
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Hughes, R. ed., 2008. Patient safety and quality: An evidence-based handbook for nurses (Vol.
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Nccmerp (2019a). About Medication Errors. Retrieved From: https://www.nccmerp.org/about-
medication-errors
Nccmerp (2019b). Recommendations for Healthcare Organizations to Reduce Medication Errors
Associated with the Label, Labeling, and Packaging of Pharmaceutical (Drug) Products
and Related Devices. Retrieved From: https://www.nccmerp.org/recommendations-
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Pharmacytimes.com. (2016). What to Do When You Make a Medication Error. Retrieved From:
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what-to-do-when-you-make-a-medication-error
Qlicksmart. (2019). Impact Of Medication Errors On Patients, Healthcare Providers And
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v=c86ee0d9d7ed
Rogers, A. E., Dean, G. E., Hwang, W. T., & Scott, L. D. (2008). Role of registered nurses in
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Salas, E., & Frush, K. (2012). Improving patient safety through teamwork and team training.
Oxford University Press.
Vaismoradi, M., Griffiths, P., Turunen, H., & Jordan, S. (2016). Transformational leadership in
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management, 24(7), 970-980.