Medication Errors: A Literature Review your name here
Pharmacology 2 teachers name here
September 17 2008
The American Society of Hospital Pharmacists define a medication error as “episodes of drug misadventure that should be preventable through effective systems controls involving pharmacists, physicians and other prescribers, nurses, risk management personnel, legal counsel, administrators, patients and others in the organizational setting, as well as regulatory agencies and the pharmaceutical industry” (Armitage, G., & Knapman, H. 2003 ).This paper shall discuss the various causes of, and methods for the prevention of medical errors. In looking at this important and complex topic it is hoped that healthcare
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One patient required treatment with naloxone and the other required additional monitoring, ISMP Canada alerted the manufacturer who subsequently made changes in their packaging.” (Koczmara, C., Dueck, C., & Jelincic, V., 2006). Additionally from the preceding example we can see the positive effect of reporting medication errors. In that case it took only two reports to affect a change in the system towards preventing further errors from happening. Also from a liability standpoint up front reporting of medication errors is a good thing. “ ... the likelihood of being sued after such an error often depends on how the hospital responds when the error is discovered. If they revealed the error, and then made attempts to change the process that results in this error, that is always a good start.” (Kanjanarat, P., et al). These two examples highlight the importance of reporting medication errors and near misses. Nurses as the front-line healthcare providers shoulder a great burden of responsibility in the prevention of medication errors. “ Front-line health care practitioners are often safety nets preventing errors from reaching patients.” (Koczmara, C., Dueck, C., & Jelincic, V., 2006). It is because of this that every effort should be made with regard to implementing effective strategies to reduce the risk of medication errors. The five rights, right route, right
When it comes to medication errors several things may occur, such as adverse drug event, unexpected deterioration, and even death in severe cases. AHRQ (2015) states, “an adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits 100,000 hospitalizations each year.” There are many ways that errors may occur such as dispensing errors, prescription errors , administration errors, and failure to monitor patient’s progress to name a
The most important and complex system factor is medical administration. It includes multiple process in corporates prescribing, interpreting, apportioning, and overseeing medications and checking patient reaction (Anderson, 2010
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
Reckoning Medication Errors lays out a blueprint for change in medicinal prosperity. Unmistakably providers have various
The Institute of Medicine (IOM) report, To Err is Human, highlighted the prevalence and devastation caused by medication errors in the US healthcare system. The 2000 Report declared that the rates of medication errors and subsequent adverse drug events (ADEs) are unacceptable and immediate action to decrease these rates should be a national priority. In a later Report, the IOM committee estimated that nearly 1.5 million ADEs result from preventable medication errors annually, contributing to over $3.5 billion in avoidable healthcare costs.
Once it is established that medication error occurred and a patient wants to proceed and take legal action, medication errors usually are prosecuted under the tort law. Burkhardt and Nathaniel (2014) indicated that tortious
During my N364 clinical, I had patient H.B., a 85-year-old, African American, female patient with a long history of medical problems most notably: hypertension and type 2 diabetes mellitus. One of the responsibilities I was in charge of for this patient was medication administration. I spent the morning researching the medications that H.B. would be receiving that day. Prior to dispensing any medications, I assessed the patient’s vital signs.
Medication errors have always been a problem; even today they still loom about health care facilities such as hospitals and assisted living homes. A medication error is as an error in the process of providing care for a patient that has potential to harm the patient. There also many different ways those medication errors can occur, prescription, preparation, distribution, transcription, administration and monitoring. “It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths,” (Wittich et al, 2013). Of those different ways medication errors can happen, all of them have multiple factors that go into them that can cause an error to occur. Medication errors cause many
There are a lof ways to prevent medication errors for example ISMP is something being used to prevent those medication errors, and it stands for the Institute for Safe Medication Practices and it is based on suburban Philadelphia. ISMP started about 35 years ago and it has always been the foundation of its medication error prevention efforts a volunteer practitioner will use error reporting-program to learn about all the errors that happen across the nation part of their job is to understand all the causes and share all the lessons that will help the healthcare community, and they are also responsible for reviewing all the medication error reports submitted by healthcare facilities to the Commonwealth of Pennsylvania Patient Safety Authority.
Medical errors occur for a variety of reasons. For example, errors can happen when proper documentation doesn’t take place. Documenting things such as allergies, medication, and past surgeries can be very important to the patient chart. Errors such as these an even cause death. “An estimated 1 million medication errors occur each year, contributing to 7000 deaths”.
Medication error is any preventable event that may cause or lead to inappropriate use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Unfortunately, among the 98,000 deaths that occur every year from medical errors in the U.S hospitals, a significant number of those deaths are associated with medication errors. This is a most significant issue we see today affecting patient safety and in turn costs in hospitals very often, poses dangerous consequences to the patients.
In most organizations, a review of the most recent medication errors will likely uncover some aspect of an ineffective double-check process. Take the time to evaluate the procedures for which you require a double check, monitor compliance, assess how often the checks are conducted as designed, and then make the necessary revisions to promote effectiveness. When employed judiciously, conducted properly, and bundled with other strategies, manual independent double checks can be part of a valuable defense to prevent potentially harmful errors from reaching patients
The report makes it publicly known the harsh implications that errors in healthcare are a leading cause of death and injury. In the late1999, Institute of Medicine (IOM) of the National Academies of the United States released the report, To Err Is Human: Building a Safer Health System. The report cited the findings of a major study that found medical errors kill at least 44,000 and perhaps as many as 98,000 Americans in hospitals each year. Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (l6, 5l6). Total national costs are estimated to be between $37.6 billion and $50 billion for these events. A depressing comparison of about 6,000 Americans die from workplace injuries every year and medication errors are estimated to account for about 7,000 of this deaths (Gray, E., Gray, I., Yodice P., Rezai, F., Fless, K.).
Drug errors or drug-related injuries are one of the most serious medical mistakes that can happen in hospitals, occurring in about half of surgeries. Examples of treatment medical errors are errors in issuing the treatment, dose or method of using a drug, error in the performance of an operation, a test, or procedure. Avoidable delays in treatment, responding to a test, and giving inappropriate care also examples of treatment medical errors. Medical error is defined as a preventable adverse effect of medical care whether or not evident or harmful to the patient. Often viewed as the human error factor in healthcare, this is a highly complex subject related to many factors such as incompetency, lack of education or
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