Critical Evaluation of Medication Errors: Inter-professional Practice

This essay critically evaluates medication errors within Australian healthcare settings, examining their prevalence, consequences on patients, families, and the healthcare system. It assesses two inter-professional practice approaches for prevention, highlighting potential barriers and strategies to overcome them. The essay cites a literature review indicating a rise in medication error-related hospital admissions and discusses the impact of errors on healthcare professionals' mental wellbeing, potential legal issues, and the healthcare facility's reputation. It proposes strategies such as transparent error confession and a no-blame system, while acknowledging barriers like lack of reporting systems and fear of lawsuits. The essay concludes by emphasizing interpersonal communication, training, and audit schedules to improve patient safety and reduce medication errors.

Running head: ASSESSMENT 1: WRITING ESSAY
INTER-PROFESSIONAL PRACTICE & PATIENT SAFETY
Name of the Student
Name of the University
Author note

1ASSESSMENT 1: WRITING ESSAY
As the world population is increasing, healthcare is facing more challenges than it used to
face before. Increasing amount of patients and their interventions has put tremendous stress on
the healthcare professionals and the reason is stress is to provide adequate quality care to each
patient within a healthcare facility (Keers et al., 2013). According to the World Health
Organization, The definition of medication error states that any controllable event that causes
patient harm or inappropriate use of that medication while in control of healthcare professional
or the patient. These error occurs due to actions such as wrong, product labeling, prescribing and
communication related fault, packaging, nomenclature, and compounding, dispensing,
administration, distributing and monitoring related mistakes (Osemene & Lamikanra, 2012). The
primary aim of this assignment is to point out the prevalence of medicational error within
Australian healthcare settings. Further the effect of this adverse condition on the patients, their
family and on the healthcare system will be described. After that two inter-professional practice
central approach will be critically evaluated so that one of those can be used for prevention of
medicational errors. Furthermore, potential barriers while achieving those targets and the
strategies to overcome the barriers will be mentioned.
To understand the prevalence of medicational error in Australia, the literature review
conducted by the Australian Commission on Safety and Quality in Healthcare should be
mentioned as it was aimed to understand the medication safety in Australia. According to
Roughead, Semple & Rosenfeld (2016), the literature review was conducted within the time
frame of 2008 to 2013 and review was conducted on various stages of the patient’s hospital
journey and collected data related to Adverse Drug Reaction or ADR or error rate related
hospital stay. While statistically analyzing the medication error related hospital admissions, it
was observed that the error rate risen from 1.4% to 3% in the chosen timeframe (Keers et al.,

2ASSESSMENT 1: WRITING ESSAY
2013). Further while analyzing the hospital charts related to admission to hospital it was
observed that more than 60% people felt that they were suffering from medication error in their
previous healthcare settings, while within the current healthcare setting the error rate was 1.25%
per patient. On the other hand, the literature review also incorporated rates for prescription
related medication error and according to the research, the medication error related to
prescription was found to be 5 to 11% (Barton et al., 2012). Whereas, while medication I
healthcare facilities, the rate was found to be 9%. Finally, the medication error while discharge
was found to be 11%. Therefore, from this above discussion, of medication error in healthcare
settings of Australia, it was found that medication error is one of the prevalent adverse condition
the patient and the healthcare facilities are facing currently in Australia (Dooley, Wiseman & Gu,
2012). If the rates are calculated statistically, there in 0.5% medication error related event occurs
in Australian healthcare settings every day. However, there is a lack of recent literature reviews
that can demonstrate the current prevalence rate of medicational error in Australian healthcare
facilities. However, if the current challenges of healthcare settings is considered, the rate is
supposed to increase in current times (Barton et al., 2012).
While describing the consequences of medication error on patients, their family and on
the healthcare facility, the situations when such error can occur should be discussed. According
to Quélennec et al., (2013), medication error may occur while prescribing or administrating
medicine to a patient, further medication error can also be unintentional and such situation may
also arise that patient is exposed to a medicine which effects his or her health adversely.
Moreover, intentional misuse can also be seen. These medicational errors are preventable and
when a patient is harmed by any preventable medical error, a feeling of betrayal and disbelief
emerges that affect the wellbeing of the patient (Flynn et al., 2012). Effect of such errors made

3ASSESSMENT 1: WRITING ESSAY
by healthcare professionals affect their mental and professional wellbeing as well. They develop
feelings such as shame, disgust, guilt and self-doubt and the adverse effect of this mental health
condition can be drastic. While conducting a research regarding this issue, Radley et al., (2013)
mentioned that nurses and doctors develop suicidal behavior in the maximum incidences after
them intentionally or unintentionally commits any mistake while providing care to a fragile
patient. Majority of the healthcare experts due to this shame and guilt are unable to inform their
patient regarding medicational error they performed and according to Hartnell et al., (2012), only
5% healthcare experts confess their medicational errors in front of the patients. Therefore, they
themselves close their chance to reconcile and amend their errors as confessing their errors to the
patient could have provided them with mental force and courage to review and change the
system that made them commit mistakes that could have been life threatening to the patient.
Further, legal issues might also affect the medical profession of the healthcare professionals as
the family of the patient is free to file compliant regarding any such medicational error occurred
in the healthcare facility. This action might result in revoking the license of the healthcare
professional and hence, with a tremendous emotional pressure and stress, the career of the
healthcare professionals is affected due to medicational error (Flynn et al., 2012). On the other
hand, the healthcare facility or hospital can also face lawsuit as the hospital is also liable for the
incident. It can lead to huge settle cost and the reputation of the hospital is put on stake. Further,
the hospital might face less productivity as the healthcare professionals making medicational
error might not be able to continue their work with the hospital due to guilt and shame (Radley et
al., 2013). Furthermore, maximum of the time will be spend on investigation, prevention,
identification of the medicational errors. Hence, the hospital will become stagnant and no further
improvement will be seen in case of technology, affecting the reputation and re-accreditation of

4ASSESSMENT 1: WRITING ESSAY
the hospital. Hence, medicational error not just affect the patient, and its family, but also the
healthcare expert and the healthcare facility as all of them loss their most precious aspect due to
medicational error (Hartnell et al., 2012).
In the previous sections, the assignment describes different consequences of medicational
errors and their types that affect the patient, the healthcare facilities and the professionals dealing
with it (Vertino, 2014). Hence, there should be some strategies to deal with these medicational
errors within healthcare system. These strategies should enhance the inter-professional practice
among the healthcare facilities so that error free practice can be determined. The First strategy
should involve the healthcare professional confessing his or her mistake if any medicational error
occur and provide a detailed strategy to the healthcare facility that will eliminate the error from
his or her practice. According to Toles et al., (2012), this will enhance the transparency in the
healthcare system and healthcare facilities will be able to understand the reason and a proper
framework through which the error will be eliminated from the practice. However, Johansen
(2012) thinks that such confession will be demotivational for the healthcare professional and
they might develop suicidal tendencies as accepting the fault weakens the person and destroys
the self-confidence. Hence, the healthcare facility should ask the justification in personal
conversation with the healthcare professionals. Further, the healthcare experts should arrange a
meeting in private with the healthcare facility and discuss the error and the measures that can be
used for preventing medicational error. So that a structured framework to deal with such error is
present within the system (Toles et al., 2012).
The second inter-professional strategy that can be used to deal with medicational error is
implementing a no-blame error in the system. If the healthcare facility directly charges a

5ASSESSMENT 1: WRITING ESSAY
healthcare expert for the medicational error he or she has made and loudly announces such
incident within the system, there is a high probability that the healthcare expert will never
confess any medicational error again (Antunes-Alves et al., 2014). Hence, instead of blaming the
professional for the error, the facility should focus on implementation of strategies that can help
to eliminate that mistake and reinforce a strong and error free system. Researcher also agreed to
this strategies and Thoma et al., (2015), determined that it will help to maintain a positive
thinking within the thought process of the healthcare facility and he/she will take necessary steps
to eliminate the error from his/her process.
Unlike each positive strategies, implementation of above-mentioned strategies is also
associated with facilitators and barriers that help the facility to implement the safe healthcare
medication system within the system (Hosseinzadeh et al., 2012). The primary barrier is
associated with the lack of an error reporting system within healthcare systems that leads to
spread the medication error related news within the entire system. Therefore, it is the duty of the
healthcare facility to develop an error reporting system in the facility so that privacy can be
maintained (Hartnell et al., 2012). Secondly, the system lacks a feedback system that would have
helped them to understand the extent of their errors and prevent them. Further the healthcare
experts do not understand the reporting process and are unable to differentiate between things
that can be reported and actions that can be taken to prevent that error (Holmström et al., 2012).
Furthermore, fear of lawsuits, fear of blaming process, and documentation of medicational error,
lack of ability to recognize medicational error and an anonymous or non-consisted definition of
medicational error are some of the barriers that prevent the healthcare exerts to attain high
accuracy in their healthcare related job. These barriers are divided among individual,

6ASSESSMENT 1: WRITING ESSAY
organizational and patient related aspects hence, cumulative effort will be needed to eliminate all
the efforts from the healthcare system (Haw, Stubbs & Dickens, 2014).
Interpersonal communication is the primary way to overcome any barrier in the
workplace as Makary & Daniel (2016) determines it as the best and most effective way to
communicate any problem or concern to the facility. The healthcare facility should enhance or
motivate the employees to develop interpersonal communication so that medicational errors can
be prevented from the base. The primary reason for medicational error is non-conveyance of
important messages from one healthcare facility to another (Mueller et al., 2012). Therefore, the
healthcare facilities should implement this strategy to overcome medicational error related
barriers. Further, the hospital should develop proper medicational error reporting process and
form so that all the personal barriers related to shame, disgust, guilt so that severe errors related
to the system can be eliminated. Hence, improving the channel between the higher authorities or
managers of the system and the front line healthcare experts will help to remove all the
misunderstandings related to process and create a smooth pathway for developing error free
process (Kwan et al., 2013). Further, the healthcare facility should implement audit and training
related schedules in the system so that any internal fault and defect in the system can be
implemented in the process. Further, the healthcare experts should provide with trainings so that
stigma, behaviors and attitudes of healthcare experts towards patients can be reduced (Pham et
al., 2012). Further, the healthcare facility should implement strategies to reduce the frequency of
medicational errors in the healthcare facility so that the accreditation and reliability condition can
be improved. Drill situations involving medication error related situation should be included in
the practice sessions so that the healthcare experts become aware of the situation and take
important steps to deal with it (Graber et al., 2012).

7ASSESSMENT 1: WRITING ESSAY
While concluding the assignment, the adverse condition of medication system related to
medication error should be mentioned as it is one of the most prevailing reason for long hospital
stays and increased causalities within healthcare system. This is one f the prevailing issues that
the healthcare facilities around the world are facing nowadays, Therefore, the assignment
mentioned several reasons due to which such incidence are occurring within the healthcare
system. Further, the prevalence nature of this error in Australian healthcare system was discussed
with reference of authentic literatures. The effect of medication error on patients, their family,
the healthcare professionals and the healthcare facility was discussed. Different barriers that
prevent the healthcare facility to achieve error free medication system was discussed in the
assignment and means or strategies to remove those barriers and achieve excellence was
mentioned in the assignment. Hence, finally it should be stated that with proper strategies and
conviction, the healthcare facilities should implement strategies so that medicational errors can
be minimized in the hospitals.

8ASSESSMENT 1: WRITING ESSAY
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