Medication Errors During Transition Of Care

Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.

Nurses are responsible for multiple patients on any given day making medication errors a potential problem in the nursing field. Medication administration not only encompasses passing medication to the patients yet begins with the physician prescribing the medication, pharmacy filling the correct prescription and ending with the nurse administering and monitoring the patient for any adverse effect from the medication. According to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), ‘A medication error refers to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional,

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

In Australian hospitals medication administration errors make up 9% or 1 in10 of all medication administrations. These errors include wrong doses, wrong intravenous infusion rates and errors made by prescribing doctors. Errors on discharge of patients were increasingly higher with up to 2 errors per patient related to doctors transcribing discharge medications (Roughead, Semple, & Rosenfeld, 2016).

Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of

Medication Reconciliation is defined by the Joint Commission as the process of checking and rechecking a patient’s current medication list to the patient’s orders. Within a MedRec program, three steps must be followed to ensure patients have the correct medications at admission and discharge: Verification, Clarification, and Reconciliation (Greenwald et al., 2010; Ruggiero et al,. 2015). MedRec should not occur once, but multiple times especially when a patient moves from department to department. The more a patient moves, the more liable they are for a medication error due to poor communication. MedRec is done for the simple reason of catching those medication errors and correcting them before they can do any harm (The Joint Commission, 2006). Medication errors effect nearly 1.5 million people who enter the hospital setting in the USA. At least every patient has one medication discrepancy between admission and discharge, which leads to rehospitalizations due to hospital-setting medication errors (Institute of Medicine as cited by Wilson et al,. 2015). With nurses at the forefront of a patient’s medication regime, pressure is put on them to provide the necessary education and safety to prevent medication related rehospitalizations. Included in the causes for medication errors is miscommunication between departments taking care of the same patient (Allison et al., 2015). Many medication errors are preventable by the implementation of electronic orders. The use of electronic

Medication errors are focused on: terms and definitions; incidence of and harm; risk factors; avoidance; disclosure, legalities & consequences (Wittich, Burkle & Lanier, 2014). Medication errors categories have been developed by the American Society of Health-System Pharmacists (ASHP). Examples of these categories are based on prescribing, omitting drugs not administered, timing, unauthorized drug, wrong dosage, wrong preparation, expired drug, not using laboratory data to monitor toxicity (Wittich, Burkle & Lanier, 2014). Additionally, this article examines in depth common causes leading to medication errors, drug nomenclature, similar sounding drugs, unapproved abbreviations and handwriting, medical staff shortages and manufacturer medication shortages. Even though this article provides an informative overview for physicians, other allied health personnel may benefit too. This is valuable knowledge for the health care professional not just physicians in order to provide safe care for their

Errors made while administering medications is one of the most common health care errors reported. It is estimated that 7,000 hospitals deaths yearly are attributed to medication administration errors.

There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.

As a student pharmacist, I am interested in medication errors and initiatives for their prevention. In response to the IOM’s report, the Food and Drug Administration (FDA) agency enhanced its error reduction strategies by implementing a new division dedicated to medication errors.3

Medication error is defined as the following by the National Coordinating Council for Medication Error Reporting and Prevention: “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010). Medication errors cause increased length of patient hospitalization and morbidity and mortality (Pape

The significance of this paper is to compare and contrast various risk factors related to medication errors in neonatal and geriatric patients. Medication errors are highly common in hospitalized patients across varying age spectrums and are highly prioritized in various healthcare systems around the world. Medication errors can be defined as any irregularity that occurs during the procedure of giving or using medications. Drug errors can arise from prescribing, dispensing, transcribing, administering and monitoring medicines (European journal, 2015). The essay explores and identifies specific risk factors of medication errors related

In today’s current fast-paced and demanding field of heath care, medication administration has become complex and time-consuming task. Approximately one-third of the nurses’ time is used in medication administration. There is much potential for error because of the complexity of the medication administration process. Since nurses are the last ones to actually administer the medication to the patient therefore they become responsible for medication administration errors (MAE). Reasons for MAE may include individual factors, organizational factors or system factors. This paper will discuss the root causes analysis of MAE and strategies to prevent them.

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error

The National Patient Safety Agency (NPSA 2010), defines a drug error as ‘any preventable event that may cause or lead to inappropriate use of patient harm. Although not all drug errors have lead to patient harm it is important to recognise that if a mistakes has been