Critical Analysis of Medication Errors in Nursing Practice

This report critically analyzes the issue of medication errors within the nursing profession, focusing on patient safety and the legal and professional responsibilities of healthcare providers. It begins by highlighting the prevalence of medication errors in Australia, citing statistics on adverse drug reactions and their impact on patient outcomes, particularly among older adults. The discussion section delves into the importance of adhering to the 'Five Rights of Medication' and the potential for a sixth right—documentation—to mitigate errors. The report explores the challenges in critical care units, where errors related to incorrect administration routes and 'Look Alike Sound Alike' medications are common, and it offers strategies such as Tall Man Lettering and consultation with colleagues to enhance safety. Furthermore, the report examines the role of the National Safety and Quality Health Service (NSQHS) standards and the Nursing and Midwifery Board of Australia (NMBA) professional code of conduct in ensuring safe medication practices and patient-centered care. The conclusion summarizes the evidence-based strategies to improve patient outcomes and avoid medication errors, emphasizing the importance of compliance with relevant legislation and quality standards.

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Name of the Student:
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Introduction:
According to a report published by the Australian Bureau of Statistics (2019), it has
been stated that medication error forms one of the leading causes that attribute to a large
number of deaths across the Australian territory. Research studies suggests that
approximately 2% to 4% of the hospitalisations are on account of adverse medication error
(Roughead et al., 2016). Specifically in this regard, it has been mentioned that the incidence
of adverse medication error is mostly predominant among 30% of the hospitalised patients
that are aged 75 years and older (Tong et al., 2017). Also, 27% of the overall medical cases
recorded in the year 2015 were related to adverse drug reactions (Tong et al., 2017). Having
discussed the background information, this paper intends to discuss the legal and professional
responsibilities of the care professional with regard to correctly delivering the medication so
as to acquire positive patient outcome and promote increased patient safety.
Discussion:
This suggests that medication error is a serious issue within the Australian healthcare
system that attributes to a large number of mortality and at the same time enhances the
cumulative disease burden which diminishes the overall quality of life of the patients. Most
of the medication errors were reported within intensive critical care unit and the most
frequent medication error was reported to be incorrect dose of administration (Hayes et al.,
2015). The evidence base suggests that medication errors can be avoided by stringently
adhering to the five rights of medication. The Five Rights of Medication also known as 5 R’s
of medication, provides a routine protocol to care professional to administer the prescribed
medications in a correct manner to promote patient safety (Cairns et al., 2016). The five
rights include, right client, right route, right drug, right dose as well as the right time or the
administration of the drug in a routine manner. Research studies mention that often a sixth

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right is also added to the list of five rights and that includes, right documentation (Johnson et
al., 2017). The right emphasises upon the documentation of the patient medication for further
reference. As stated by Cloete (2015), an improved knowledge about the five rights of
medication assists care professionals to administer the medication in a correct manner and
reduces the probability of an adverse medication error. According to Cairns et al. (2016),
emergency departments or intensive care units are usually centres of strenuous clinical
environment and on account of the nature of urgent care delivery, these areas are susceptible
to a large number of medication errors. Errors with respect to ‘incorrect route of
administration’ as well as ‘incorrect medication preparation’ in relation to ‘Look Alike Sound
Alike’ medication is common within the identified critical care units. Research studies
mention that adapting precautionary method such as the use of Tall Man Lettering in case of
dealing with ‘Look Alike Sound Alike’ medication can significantly reduce chances of
medical error. Tall man lettering can be defined as a procedure that helps to differentiate
‘LASA’ medication, as in case of ‘predniSONE’ and ‘predniSOLONE’ (Hayes et al., 2015).
Instances of wrong route of administration can be avoided by consulting with fellow RN or
the Leader Nurse (Roughead et al., 2016). Research studies further mention that compliance
with the five rights of medication is the most effective strategy to avoid instances of
medication error (Cloete, 2015). Further, following an appropriate medication reconciliation
procedure while arranging a transfer of patients from one unit to the other or to a different
clinical setting can help improve patient safety (Cloete, 2015). In addition to this, re-
evaluation of the ordered medication procedure and consulting with the physician in case of a
confusion can help acquire positive outcome (Johnson et al., 2017). Further, the use of name
alert to differentiate sound alike medication and placing zero before the mentioned decimal
dose can also prevent chances of medication errors (Tong et al., 2017). In addition to this,
proper documentation of medication orders, consulting with a drug guide, ensuring proper

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storage of ordered drugs and having a thorough knowledge about the healthcare organizations
medication administration guidelines and policies can help to acquire increased patient safety
and positive patient outcome (Cairns et al., 2016; Cloete, 2015).
The fourth standard of the NSQHS standard focuses on ensuring medication-safety
and expects care professionals to safely prescribe, dispense and administer medication to
patients so as to promote increased patient safety (Safetyandquality.gov.au, 2019). The
standard expects care professionals to adapt improved clinical governance so as to assure
quality outcome in relation to medication safety (Safetyandquality.gov.au, 2019). Also, the
standard expects care professionals to communicate effectively at clinical handover and adapt
appropriate measures to improve the quality of clinician-patient interaction so as to establish
a positive therapeutic relationship and render safe and effective care delivery
(Safetyandquality.gov.au, 2019). Also, under the intent of the standard care professionals are
expected to make use of technology to facilitate easier transfer of information and provision
improved access to support pertaining to clinical decision as well as patient information
(Safetyandquality.gov.au, 2019). Also, the NMBA professional code of conduct expects
nursing professionals to prioritise patient care and adapt a person-centred care approach so as
to deliver care in a safe and effective manner (Nursingmidwiferyboard.gov.au, 2019).
Further, the NMBA code of conduct also expects care professionals to practice legally and
comply with the relevant legislation and quality standards (Nursingmidwiferyboard.gov.au,
2019). Failure to comply with the standards can invite severe legal action including
cancellation of licensure (Nursingmidwiferyboard.gov.au, 2019).
Conclusion:
Therefore, to conclude, it can be mentioned that the paper has clearly presented the
evidence based strategies that can help to improve patient outcome and avoid episodes of

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medication error within intensive care unit. In addition to this, the paper has also presented an
overview about the NSQHS quality standards and the NMBA professional code of conduct
under which care professionals are expected to prioritise patient safety and comply with the
relevant legislations so as to deliver a safe and effective care that helps to acquire positive
patient outcome.

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