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Medication Errors
Sarai Artires
Capella University
Developing a Heath Care Perspective
Analyze a Current Health Care Problem or Issue
January 2019
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Medication Errors
Professionals working in the health care field take a Hippocratic oath to swearing by
several healing Gods that no harm will be done and to uphold specific ethical standards. Despite
this, medication errors have been statistically proven in the United States as the third leading
cause of death in inpatient settings, Makary, M. (2016). It is a high priority for healthcare
facilities to focus on improvement of patient safety and reduce the number of errors. Multiple
approaches have been developed to help avoid circumstances of flaw in the cycle from
prescribing up to distribution. But innovative ideas urgently must be addressed to be able to
reduce these statistics in the long run.
Medication errors are preventable adverse effects that can be provoked by overlooked
effortless mistakes. Health care field is an extremely preoccupied field, in which a lot of
professionals are constantly running around assisting multiple patients and families at the same
time. A doctor can rapidly prescribe by hand a medication for a child’s fever with cough, and
easily be confused with the wrong medication from the illegibility of the handwriting. In this
case, multiple electronic systems have been exposed to the use of employees and doctors to
prescribe medication in text form while also using a drop-down menu for dosages and routes of
medication administration. “It provides an audit trail for medications prescribed and dispensed
and eliminates confusion over illegibility or incomplete prescriptions” Nute, C (2014).
Although, this problem was addressed and attempted to improve, the possibility of incorrectly
selecting the 2.0mg instead of 0.2 mg is still available. Furthermore, automated dispensing
cabinets are also involved in the improvement of patient safety. The purpose is to offer a single
point access to medication to avoid confusion. But, from personal experience, a brief time ago,
meanwhile dispensing the routine morning medications I was interrupted, then I resumed to
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finish gathering the drugs. Prior to administering my morning medications to my patient, I was
able to acknowledge that I had retrieved double the doses on all medications thanks to our
portable computers and scanning system mechanism to which secures certainty of correct patient
and correct medication.
In Addition, error hiding is costly to hospitals and patients. Kingston (2011) stated that at
least fifty perfect of medication errors go unnoticed or, and unreported considering a harmful
event didn’t occur. And a large, average amount of 3.5 million dollars cost per year in a hospital
framework. Extensive financial burden for both the hospital and the patient, as well as elongated
hospital stay and specially, significant harm to the patient. A potential solution to this issue is to
establish an environment starting from nursing school, in which it is comfortable enough to
confront any disputes and learn from mistakes to avoid future occurrence. This way, it will
benefit nurses by coaching in a nursing career to report all error in the process of administration.
Kingston (2011) found that guilt, shame, imperfection and questioning one’s competence, was
the universal response by nurses when interrogating about these errors. These realistic factors
will intervene in the ethical confession of a nurse or health care professional, due to fear of
incapability or the likeliness of penance. Some felt that it had affected their practice, and others
stated that medication errors reinforced their responsibility (Fry and Dacey 2007). Nurses are
employees in an ethical environment in which moral distress is presented more than often. It is
morally proper to report even the meaningless causes of errors in administration because it will
be helpful to co-workers and you avert repeating the same misstep more than once. Fortunately,
as an employee of a hospital, a certification of completion of continued education of medication
errors has remained a mandatory yearly teaching to reinforce how to safely perform this highrisk activity.
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Corners tend to be cut to facilitate our work load and speed through our medication
administration to have excess time for detailed documentations. We think ahead of ways to
make our job easier not realizing inaccuracy is still possible. Medications should be dispensed
patient by patient, to dodge the chance of mixing up two patient’s medications causing a very
harmful event. Moreover, a multiprofessional approach is required in this complex process. The
Five Rights are no longer enough, several other steps have been summed to provide more
accurate expected outcomes. Nurses must firstly identify if the prescribed medication interacts
with any other current medication the patient is taking at the moment and if there is any allergies
to the medication before the following to correctly proceed with distribution: Right patient by
verifying name, date of birth and patient account number comparing with ID band, right reason,
right route (PO, IV, IVP, SB, IM, etc.) right dose, right time and finish with right documentation.
Not only does guidelines support the purpose to aid prevention but we also have protocols per
policies to rely on. For example, Heparin drip has a strict protocol in which is followed to
accurately calculate the precise amount for a specific patient according to the lab values of the
PTT. Skilled nurses are required to set up the drip rate by following the steps in the protocol.
This drug is a high alarm due to the risk of perfuse bleeding as an adverse effect.
Every patient is exposed to the potential harm irrelevant to the patient’s age, gender or
race. In pediatric populations, the incidence of prescribing errors is higher than in adults stated
Glanzmann, Corina; Frey, Bernhard; Meier, Christoph R; Vonbach, Priska (2015). Reason
being, dosages need to be personally calculated based on body weight and height and
consideration of the diagnosis with possible side effects. Yet, elderly patients responsible for
taking medication at home without supervision are likely to misread or forget to take their
prescribed medications and a mistake can easily occur harming themselves.
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A possible solution to improve patient safety in inpatient settings is the chance to reduce
understaffed hospitals and assigning a maximum of five patients per nurse. With the amount of
documentation that needs to be provided per patient, we end up consuming most of the hours of
the shift sitting in from of our computers. By reducing the number of patients distributed to each
nurse responsible, would help nurses spend more time with the patient in the room and slowly
step by step go through the medications in addition to scanning the patient’s ID band and
medication barcode, one by one. Cons to this obligation would apply only if seven patients are
being assigned to nurses there will be chances that multiple approaches will be developed to
rapidly perform the medication distribution. Although, a wonderful way to prevent confusion of
medications between multiple patients is if it is only permitted to dispense the drugs of one
patient and won’t allow access to withdraw another patient’s medications before electronically
scanning the patient and his/her medications before continuing to the next. Also, health care
facilities which don’t provide mobile computers, scanners and automated dispending cabinets for
all employees authorized for the care of the patients will fail to strive in improvement in
comparison to those facilities which do.
Furthermore, this is a complex system in which multiple health care professionals interact
to achieve a peculiar goal for each individual patient. In addition, workable solutions for this
common recurring problem, would include the employee’s liability and integrity to fearlessly
report any mistake caught by the nurse, pharmaceutical, or doctor. An incident report may sound
like a scary concept to get involved with, but theoretically these are paperwork’s available for
any employee to state an issue that appeared, with the purpose of acknowledgement and
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reinforcing the legitimate process of medication administration. If we all were to document
common errors in the cycle of medication administration even if an adverse effect was thankfully
unpresented, it will emphasize the necessity for improvement. Evidence based practice will
continue to mature possibilities to aid the contribution among the heath care field to minimize
medication errors as the third leading cause of death in the United States.
In conclusion, preventing medication errors in the health care industry and other
organizations has become priority as a national concern. Medication errors can eventualize at
any stage of the medication process. Quality improvement have gained success from previously
developed changes such as the electronical medication system and the automatic dispensing
cabinets. Because of countless interruption throughout the shift of a nurse, from simple to
complex, adheres to the possible facts of administering a drug wrongly by overlooking crucial
factors. As the years pass, modern technology will evolve and support the health care system
with new regulations and strict regimen during the dispense and management of a medication in
an inpatient setting. Currently, implementing the accurate guidelines for each drug distribution
and meticulous carefulness, can automatically decrease the statistic rates of the average rate of
errors documented per year. Hospitals will benefit from the reduction in patient stay, error cost,
readmissions, and most importantly ensure the life of the patient. Variations in the health care
system will help nurses encourage patient welfare and lower the probabilities of harm.
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References
Krishnamurthy, Mahesh. (2016). J Community Hosp Inter Med Prespect. The alarming reality of
medication error: a patient case and review of Pennsylvania and National data.
Retrieved from https://www.tandfonline.com/doi/abs/10.3402/jchimp.v6.31758
Makary, Martin A. (May 3, 2016). Medical Errors- The third leading cause of death in the US.
Retrieved from
https://search.proquest.com/openview/eabbf73962ed02c6516368f715d9dd6f/1?pqorigsite=gscholar&cbl=2043523
Nute, Christine. (Nov 19, 2014). Reducing Medical Errors.
Retrieved from https://search-proquestcom.library.capella.edu/docview/1784938491?pqorigsite=summon
Kingston F, (2011). Nurse likelihood to report a pediatric medication error: Examination of the
"pre-reporting" period. (Doctoral dissertation). Retrieved from ProQuest Dissertations
and Theses database. (AAI3464803)
Fry MM, Dacey C. (2007). Factors contributing to incidents in medicine administration. Part
2. British Journal of Nursing .16, 11, 676- 681. 17577187
10.12968/bjon.2007.16.11.23690
Glanzmann, Corina; Frey, Bernhard; Meier, Christoph R; Vonbach, Priska. (Oct 2015).
European Journal of Pediatrics; Berlin Vol. 174, Iss. 10, 1347-1355. Analysis of
medication prescribing errors in critically ill children. Retrieved from https://searchproquest.com.library.capella.edu/docview/1713728558/fulltextPDF/9F93645489E6443F
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