HCM 600 Research Project: Medication Errors and Safety Improvement

This research project, conducted for HCM 600, investigates the impact of knowledge and attitude on medication errors and safety improvement within the pharmacy department at King Saud University Medical City. The study involved 167 medical students and examined their understanding of medication errors, adverse drug reactions (ADRs), and reporting practices. The findings revealed deficiencies in students' knowledge, attitudes, and practices regarding medication errors, with a need for improved education and training. The project highlights the critical role of healthcare professionals in minimizing medication errors and emphasizes the importance of standardized medication processes, reporting systems, and continuous learning to enhance patient safety. Recommendations include pharmacist involvement, double-checking protocols, and the implementation of comprehensive training programs to address communication failures, standardize medication processes, and improve overall patient outcomes. The study underscores the need for a proactive approach to reduce medication errors and promote a culture of safety within healthcare settings.

Master of Healthcare Administration
HCM 600 Research Project
Impact of Knowledge and Attitude on Medication errors and Safety Improvement in the
Pharmacy Department
Abstract
Medication error in medical is defined by as a preventable occasion that is caused by use of
inappropriate medication that results to adversative drug reaction (ADR) episode in patients.
Different tactics have been anticipated to reduce medical errors, adverse drug reaction being one
of them. The current study was premeditated to evaluate the attitude, knowledge and practice of
the students dealing with medical practice towards medical errors and adverse drug reaction
reports.
The research population was 167 medical students from King Saud University Medical
City. The legalized items connected to KAP was given to each member before
and after the research. Demographic structures of the members have no
significant difference. The informative intervention, in the curriculum of
medical students, and hold interactive clerkship in health care can improve
the knowledge, attitude and practice regarding the adversative drug reaction
reports and moderate the unnecessary medical errors.
Introduction
Medication errors occurs broadly on various steps that includes dispensing, transcribing,
prescribing and administration .It has decreased due to use of computerized physician order
administration than hand written prescription (HWP).Numerous approaches have been suggested
in detection and of the occurrence of medical errors and the way of reducing it.Adverse drug
reaction is the common approach used and mostly employed in high risk industries such as

hospitals (MQ, 2015). The healthcare organization has encouraged reporting of the medication
error and implement clear policies and guideline that encourage the healthcare provider.
Medication error reporting is the responsibility of the health care but the system is not
deliberated to determine the error rates. Though it is a safety enhanced method that takes the
benefit of astute perception of employees, which includes the principal care clinicians and other
office staff involved in the treating process, in detection of the problems that may modify the
policies, system and procedures of the quality improvement method (Kaae S, 2015). There are 5
stages involved in the ordering and delivery in the pharmacy department.it includes; monitoring,
administration, dispensing, transcription and prescription. Each phase represents a susceptible
link in the chain along a diversity of medical errors. The most joint stages that are associated
with medical error are inadequate knowledge on drug prescription and knowledge concerning the
patient whom drug is prescribed (Hickner J, 2010).
Yellow cards are the commonly tool used in the reporting system of adverse drug reaction. An
inquiries that is used in demonstration of adverse drug reaction is a significant clinical subject,
which can be entered the expensive costs of NHS and stern ADRs that can result to death.
Conferring to the World Health Organization the science and activities linking to the assessment,
detection, prevention and understanding of adversative impacts or any other drug problem is
called pharmacovigilance (Joolaee S, 2011). Training consultants provide a wide range of
medical error reporting programmes considering that many corporations have begun considering
the safety of their patient an issue of significance. Reducing the financial cost of a result of the
adverse selection reaction as a result of the malpractice. Improve the medication error reporting
enhance patient safety by correcting the bad practice by good one has a direct impact on patient
lives.
Pharmacist play the most significant role in provision of a defense mechanism in prevention of
medication error from getting into the patients. This role further advances as part of a strategy in
reduction of medication errors. Regular teaching of the drug usage can be used as a tool of
familiarizing new pharmacist with the format of drug protocols, drug charts and medication
regimens that is associated with the medical errors. New pharmacist to the unit possibly will be
joined in the related sessions that are apprehended specifically for the pharmacy staff, which

could be used in debating the medicational errors that have recently occurred. All pharmacist
must attend the session of learning every year.
Discussion
Health care professional plays a very significant role in reducing the medication errors. Other
methods used in reduction process includes; the introduction of computerized physician order
entry and the adversative drug reaction reporting which has led to advancement in detection and
prevention of the medical errors (Ivy Bourgeault, 2010).
From the result above it can be seen that the medical student have deprived knowledge, attitude
and practice to the medical error and they are not aware of the significant role of reducing it.
Patient safety overview in error detection and reporting verse ethics, human approach, and safety
tools are based on the interactive clerkship. Awareness of the patient on the medical error is by
use of appropriate and experiential curriculum (C., 2010). Findings described by the medical
students were conscious of the responsibility of adverse drug reaction reports and appropriate
attitude towards it (Austin Z S. , 2014).
Health care professional had a meagre knowledge and attitude towards pharmacovigilance the
adverse drug reaction and among the participants who have not reported even a single ADR to
the medical Centre. Facts of the ADR among the clinicians, the rate of reporting was less. The
study give emphasis to the education and exercise which are most acknowledged by the means of
advancing the ADR reporting. (C.., 2015) Thus, the proper training and appropriate curriculum
is the alternative way of improving the knowledge and attitude towards the ADRs reporting on
medical errors. This results to proper identification of causes of medication errors. Educational
presentation and intervention of the interactive research in the health care professional to report
on the critical enhancement of the practice and reduces the preventable medication error (Q.
Ashton Acton, 2012).
Medication use is a complex process that benefits from the interpretation and a regular
evaluation. There are 5 stages involved in the ordering and delivery in the pharmacy
department.it includes; monitoring, administration, dispensing, transcription and prescription.
Each phase represents a susceptible link in the chain along a diversity of medical errors. The

most joint stages that are associated with medical error are inadequate knowledge on drug
prescription and knowledge concerning the patient whom drug is prescribed (Tong A, 2014). The
appropriate way of eliminating the medical error that may arise in each of the stage is by
ensuring the standardization of medication process.
Medicational transcript error refers to communication failure between the prescribing clinician
and supply staff. In the pharmacy department it is mostly initiated by the oral medication
instruction being misheard. To avoid such medical errors, it is vital to Contrivance a protocol on
use of verbal drug orders and take steps of including some retrospective, verification and
documentation signing. Correction of medication error for the patient discharged from the
pharmacy makes use of critical redundancies. The clinicians must ensure that they have
confirmed the patient’s status of allergy, prove weight and implement double checking on
administering high risk medicine and medicational errors prone to the population (Vessal G,
2009). Administration medical errors occurs when a right drug is administered through a wrong
route or a wrong drug is administered to the patient. Safety checklist helps to eliminate such type
of errors and the staff is always encouraged to prescribe and offer dugs on the right dosage
(Zubin Austin, 2018).
Recommendations
There is need for some interpretation on the role of the pharmacist. Both of them they should
ensure that they have double checked the medication and be flawless on what they are signing
for in order to increase accountability and avoid medical errors. Administration of drugs without
proper prescription or incomplete prescription is seemed to be preferred practice. This can be
addressed in many ways, which includes; one applying the supplementary or independent
medical dosage by non-medical staff (Margaret A. Morrison, 2012). The pharmacist need to take
the initiative measure in ensuring the medication order and dosages are complete.
The pharmacist play the most significant role in provision of a defense mechanism in prevention
of medication error from getting into the patients. This role further advances as part of a strategy
in reduction of medication errors. Regular teaching of the drug usage can be used as a tool of
familiarizing new pharmacist with the format of drug protocols, drug charts and medication
regimens that is associated with the medical errors (HeffernanL, 2013). New pharmacist to the

unit possibly will be joined in the related sessions that are apprehended specifically for the
pharmacy staff, which could be used in debating the medicational errors that have recently
occurred. All pharmacist must attend the session of learning every year .Most of the staff
members felt that they could learn more from the errors committed by others if they are
discerned about them(Smith, 2010).
The only way of reporting such errors is by use of the critical incident forms that entails the
details and the name of the member of pharmacy staff involved. Medicational errors should be
reported and done secretly. The results recommended that the response on medication error was
not openly accessible. It should be availed to all members of staff (Babar, 2015). The vital needs
to be continuously developing process that will involve all rankings of the staff members. The
emphasis necessities to move away from the members of staff and focus on the causative factor.
The research provided the insight of beliefs and attitudes of healthcare practice on the sources
and reporting of medication errors in the pharmacy .Various approaches were recommended in
improving the patient safety. First the staff member must understand the importance of second
check in prescribing and administration (Vazin A, 2012) .Proactive rewriting the expiry date
prescription and making the staff conscious of the circumstances that medical errors are likely to
occur and elude relying much on the other staff to correct the error. The greater response on
medication errors is vital to advance the present situation and offer the appropriate inducements
for future reporting (Oshikoya KA, 2009).
Conclusion
Different tactics have been anticipated to reduce medical errors, adverse drug reaction being one
of them. The current study was premeditated to evaluate the attitude, knowledge and practice of
the students dealing with medical practice towards medical errors and adverse drug reaction
reports. Numerous approaches have been suggested in detection and of the occurrence of medical
errors and the way of reducing it.Adverse drug reaction being the common approach used and
mostly employed in high risk industries such as hospitals. The healthcare organization has
encouraged reporting of the medication error and implement clear policies and guideline that
encourage the healthcare provider.

Medicational error has decreased due to use of computerized physician order administration than
hand written prescription. Numerous approaches have been suggested in detection and of the
occurrence of medical errors and the way of reducing it.Adverse drug reaction is the common
approach used and mostly employed in high risk industries such as hospitals. The healthcare
organization has encouraged reporting of the medication error and implement clear policies and
guideline that encourage the healthcare provider.
The medication use is a complex process that benefits from the interpretation and a regular
evaluation. There are 5 stages involved in the ordering and delivery in the pharmacy
department.it includes; monitoring, administration, dispensing, transcription and prescription.
Each phase represents a susceptible link in the chain along a diversity of medical errors. The
most joint stages that are associated with medical error are inadequate knowledge on drug
prescription and knowledge concerning the patient whom drug is prescribed. The appropriate
way of eliminating the medical error that may arise in each of the stage is by ensuring the
standardization of medication process.
Patient safety overview in error detection and reporting verse ethics, human approach, and safety
tools are based on the interactive clerkship. Awareness of the patient on the medical error is by
use of appropriate and experiential curriculum. Findings described by the medical students were
conscious of the responsibility of adverse drug reaction reports and appropriate attitude towards
it. Only way of reporting such errors is by use of the critical incident forms that entails the
details and the name of the member of pharmacy staff involved. Medicational errors should be
reported and done secretly. The most joint stages that are associated with medical error are
inadequate knowledge on drug prescription and knowledge concerning the patient whom drug is
prescribed.
The study give emphasis to the education and exercise which are most acknowledged by the
means of advancing the ADR reporting. Thus, the proper training and appropriate curriculum is
the alternative way of improving the knowledge and attitude towards the ADRs reporting on
medical errors. This results to proper identification of causes of medication errors. Educational
presentation and intervention of the interactive research in the health care professional to report
on the critical enhancement of the practice and reduces the preventable medication error. The

greater response on medication errors is vital to advance the present situation and offer the
appropriate inducements for future reporting.
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