Medication Errors (IOM) Report

An error is one of the vital parts of human life. Hospitals are areas with very chaotic systems and as health care is growing more steadily, it is becoming complex in nature and more sophisticated technologically. Therefore, medical errors are bound to happen. Administrators, physicians, and nurses, are advocates of patient safety and safety is one of the highest priorities during the provision of care. A report from Institute of Medicine (IOM) claims that between 44,000 and 98,000 die annually due to medical errors (Alexander, Cheryl Ann 2014). Medication errors can lead to adverse outcomes such as increased mortality, extended period of hospitalization, and amplified medical expenses. Although the health care team can cause medication errors, nursing medication errors are the most common. Moreover the workload of the nurses combined with more prescription

Some errors affects patient minimally, whereas other medication errors results in patient morbidity and mortality. Despite the efforts, medication errors remains problematic in the area of healthcare. It is the health care organizations biggest challenge. Numerous research has been done to identify factors that would reduce medication error, however the emphasis on error management has been minimally to nonexistent (Admi, et al., 2013).

Research shows that medication error in hospitals and other health care settings leads to 373,000 preventable adverse drug events (ADEs) per year and that these events would increase to 478,000 within 20 years in the absence of additional preventive measures (Federal Register, 2004).

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

Prescription medication use is widespread, complex, and increasingly risky. Clinicians have access to an armamentarium of more than 10,000 prescription medications, and nearly one-third of adults in the United States take 5 or more medications. Advances in clinical therapeutics have undoubtedly resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased risks. 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 and 100,000 hospitalizations each year. ADEs affect nearly 5% of hospitalized patients, making them one of the most common types of inpatient errors; ambulatory patients may experience ADEs at even higher rates. Transitions in care are also a well-documented source of preventable harm

The words medication error elicit fear in every nurse. According to Stefanacci and Riddle (2016), preventable medication errors are responsible for third reason of death apart from heart disease and cancer in the United States. As a nurse, it is important to obtain skills and knowledge to prevent them as these errors could result in extended hospitalisation of patients, simultaneously a burden of health care cost. These errors could be reduced by identifying the problems which lead to medication errors and following certain protocols in a coordinated environment.

For the purposes of this integrative review, an acute care setting is defined as an adult general medicine medical surgical unit. The expected outcome of the integrative review will be to discover a strategy, intervention, or protocol that can be implemented within the project leader’s healthcare organization to support a sustained change. Upon dissemination and implementation of the findings, a systematic evaluation can be conducted to determine the positive or negative outcomes of the intervention. Each year in the U.S., serious preventable medication errors occur in 3.8 million inpatient admissions and 3.3 million outpatient visits. The Institute of Medicine, in its report To Err Is Human, estimated 7,000 deaths in the U.S. each year are due to preventable medication errors. Inpatient preventable medication errors cost approximately $16.4 billion annually. Outpatient preventable medication errors cost approximately $4.2 billion annually. Dosing errors make up 37 percent of all preventable medication errors. Drug allergies or harmful drug interactions account for 11 percent of preventable medication errors. Preventable medication reconciliation errors occur in all phases of care: 22 percent during admissions, 66 percent during transitions in care and 12 percent during discharge. Approximately 100 undetected dispensing errors can occur each day as a result of the significant volume of medications

Medication errors originate in multiple ways such as “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” (U.S. Food and Drug Administration, 2015). Many patients may be quick to criticize medication errors to be the responsibility of the professional who administers the medication rather than the manufacturing, production and data entry processes.

One of the many responsibilities of a nurse is administering medications. Improper transcription, dispensing, administering, and reporting can result in medication errors. The article Simple Steps to Reduce Medication Errors recognizes how detrimental errors can be to the patient and the facility (Chu, 2016). An error in medication can lead to an extended stay for the patient, resulting in serious harm or death.

In the healthcare settings, medication errors do occur at various levels. It may be prescription centred, dispensing cantered and /or administration cantered (nurse /patient

Medication errors occur more often than they should. It is recorded that medication errors occur in children every eight minutes or in every 25 out of 1900 children. Adults older than age of 65 are seven times at a greater risk of being victim of medication errors than those adults under the of age 65. What is a medication error? A medication error is a event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the healthcare professional, patient, or a consumer. The patient has to actually receive the drug in order for it to be considered a medication error. Detrimental patient outcomes are associated with medication errors. A few of the many harmful effects include medication overdose, stroke, heart attack, organ damage, harm to fetus, paralysis, and death. The numbers of occurring medication errors are staggering but they can be prevented. There a precautions to take in order to safely administer and prevent medication errors, which requires following the “six rights of medication administration”. These six rights are as followed, right patient, right drug, right dose, right route, right time & date, and the right documentation.

In response to the situation presented, a multidisciplinary QI team should review the hospital’s overall data on the incidence of medication errors that result in

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 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 causes of medications error in general practice are illegible prescription orders, dosage miscalculations, confusion between two medications sound alike, misreading drug labels and interactions, failure to check the prescription before administration and so on (Creed, 2017). Medications error are made at different levels of education. In study conducted by University of Eastern Finland, Kuopio gave the statistics, “In 2010 there were a total of 1,617 incidents reports about medication error. The 82.6 % errors was made by register nurses, 5.4 % made by pharmacists and 2.5 made by physicians.”(Harkanen, Turunen, Saano, & Vehvilainen-Julkunen, 2012). This means that it is our responsibility to prevent error regardless of the person’s title.