The National Transitions Of Care

The purpose of this paper is to address the problem of medication errors in health care facilities. 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.”

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.

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

In 1999, the Institute of Medicine (IOM) “Too Err is Human” estimated 98,000 deaths yearly due to medical error. Many of the errors are the result of adverse drug events, most of which occur during the prescribing and administration stages of medication administration (Guo, Iribarren, Kapsandoy, Perri, and Staggers, 2011). These errors are a significant cause of morbidity and mortality in hospitalized patients. One report estimates that when all types of errors are accounted for, every hospitalized patient can expect on average one type of medication error per day and during 2006, adverse drug events resulted in approximately 400,000 cases of error at a cost of over $3.5 billion (pp. 202-224). Studies have demonstrated a

Woten (2016) attributes, National Patient Safety Goals (The Joint Commission, 2016): Medication Reconciliation – an Overview acknowledges effective communication is a driven force to accurate medication reconciling. Communication to patients, families, professional to professional provides honesty along with direction in role responsibilities. Poor communication was recognized from a study at Mayo Health system, reporting, “medical information at transition points was responsible for as many as 50% of all medication errors in the hospital and up to 20% of ADEs”(Vogenberg & DiLascia, 2013). The evidence in transitions throughout care directly connects to communication validating how medication lists, if not updated or accurate cause harm to

Globally, unlike in the past, it is rare for a patient to consult with the same healthcare provider over their lifetime, often referred to as healthcare provision “from the cradle to the grave” of a patient (Mostert-Phipps, Pottas & Korpela, 2012). This rarity is credit to the fact that currently patients move between healthcare providers due to various reasons (Medical School, 2003; Naylor & Keating, 2008; National Transitions of Care Coalition, 2010; Picton & Wright, 2012; Masango-Makgobela, Govender & Ndimande, 2013). The Joint Commission (2013) terms this movement as the “transition of care”. However, this transition of care results in the fragmentation of provision of patient healthcare, and thus challenges continuity of care (CoC) (Haggerty

A third risk in a hospital is medication errors. These occur when either the pharmacist can’t read a physician’s hand writing on a prescription, or the physician does not know the patients medication history and so on. The quality outcome of the patient’s wellbeing is affected in this risk.

Causes of medication errors include mistakes by the pharmacist incorrectly interpreting illegible handwriting or ambiguous nomenclature, and lapses in the prescriber's knowledge of desired dosage of a drug or undesired interactions between multiple drugs.

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

These errors occur when a patient is administered the wrong drug, the incorrect amount of right drug, a drug that is known to cause allergy in the patient or a drug that is known to cause poor interaction with another drugs given to a patient. Additionally, not prescribing the medications that are known to treat the patient’s illness in a positive way is also called as medication error. This type of error can happen due to lack of up to date information, miscommunication due to poor handwriting or resembling drug names and dosage.

Medication safety is a general term used to describe any event related to the patient's safety upon using medications. In order to ensure the safety of the patients, the term medication error was developed. Medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a HCP, patient or consumer,” as defined by WHO. Medication error can occur at any level of the medication use process, which involves prescribing, dispensing, preparation, labeling, administering or monitoring the medication. Therefore, determining and resolving medication errors are significant parts of the pharmacist role.

Medication errors in hospitals are common, expensive and sometimes harmful to patients. It has been found that mediation errors and adverse drug reactions most frequently occur at the drug ordering at prescribing stage (31). Therefore, the main objective of this study was purposed to know the occurrence of medication errors and the frequency of errors which were happened in an outpatient hospital settings.

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

An inappropriate medication use that can harm a patient or no therapeutic effect is considered as the pharmaceutical error, as according to the Malaysian National Patient Safety Council. The pharmaceutical error can be caused by the mistakes done by physicians, pharmacists, healthcare professionals, nurses or patients itself in either diagnosis or administration of drugs. The pharmaceutical error is an event that can be prevented. Generally, every step in treating of a patient, including diagnosis, dispensing of drugs and administration, should be done accurately without estimation. The consequences of medication error can lead to complication or death in patients.