The Problem Of Medication Errors

The results of this study was that the percentage of medication errors decreased following the implementation of eMARs. Although medication errors were decreased, the authors found that the eMAR system decreased efficiency and disturbed workflow. The authors state that factors such as missing medications, preparing medication at the bedside, and distractions contributed to this and are factors that can be improved. The author’s identified the presence of several limitation in the study. The use of one individual to collect data created a possibility of bias and the observation of nurses may have affected the behaviors of the nurse. Also, the authors state that the study was not a cause and effect study and was only conducted on one unit which decreased the generalizability of the study. According the hierarchy of evidence for intervention studies, this

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

The Inner City Clinic is experiencing problems with medication prescribing errors and seeks a resolution to this problem through use of electronic medical records and registration medication reconciliation. The Institute of Medicine reports in the work entitled "Preventing Medication Errors" that the "average hospitalized patient is subject to at least one medication per day. This is reported to confirm previous research findings that medication errors represent the "most common patient safety error." (Barnsteiner, nd, p.1) Medication reconciliation is described as follows:

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.”

This study described discharge prescription medication errors written for emergency department patients. This study used content analysis in a cross-sectional design to systematically categorize prescription errors found in a report of 1000 discharge prescriptions submitted in the electronic medical record in February 2015. Two pharmacy team members reviewed the discharge prescription list for errors. Open-ended data were coded by an additional rater for agreement on coding categories. Coding was based upon majority rule. Descriptive statistics were used to address the study objective. Categories evaluated were patient age, provider type, drug class, and type and time of error. The discharge prescription error rate out of 1000 prescriptions

Majority of errors are thought to be preventable, and multiple interventions may be required to significantly decrease medication errors, particularly when patients transition between healthcare settings.

In 2011, over 3,800 of these “never events” where reported to the Joint Commission (psnet, n.d.). Being an Administrator in a hospital setting, it is import to know what SRE’s mostly occur. Many of the SRE’s reported in 2011 were linked to surgical events such as wrong-site surgery, air embolism, death or disability due to medication errors, patient suicide and environmental events such as fires, which can harm anyone in the facility (psnet, n.d.). 8.2% of the serious reportable events reported to the joint commission where medication errors, nearly 600 reports are medication errors. This happens when a patient dies or is seriously injured due to a medication error such as being administered the wrong drug or the wrong dose, it was given to the wrong patient, at the wrong time or wrong rate or had the wrong preparation, or wrong route of administration (psnet, n.d.). Mediation errors are the most important or relevant to hospital setting

medication error is and how it can have an impact on the nursing team or organizations was

The administration of medication can be associated with a significant risk with it is recognized as a central feature of the nursing role. It should continue in order to avoid a possible medical malpractice continuous care. Nursing staff have a unique role usually given to patients to manage their medication and responsibilities, then they can report these identified medication errors. Some of the most distinguishable events can be related to errors in professional practice, prescribing, dispensing, distribution, and education or monitoring. Since medication errors can arise at any state of the administration process, it is essential for nursing staff to be attentive of the most commonly encountered errors. For the most part, the common of the perceptible aspects related with medication errors are due to minimal awareness about hospital policies, inappropriate implementation or latent conditions (Farinde, n.d).

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

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).

Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”. Ensuring medication reconciliation to the patient, health providers and any new consults that are

For many patients the scariest part of being in the hospital is having to rely on other people to control your life changing decisions. One large part of this is the medications one is given while in our care. I can only imagine what it must be like for patients to have a stranger to come in and start administering drugs to me. This would be especially scary if I did not know what these medications did, or what negative effects could be caused by taking them. Unfortunately, the fear of medication errors that many patients have are not unfounded. Estimates range from 1.5 to 66 million patients a year have medication errors occur while they are in the care of health care professionals. Considering all of the technology we have at our

Strategies targeted at preventing medications errors are discussed in the subsequent sections. These strategies are aimed at distinct stages of the inpatient medication delivery process and other risks that often contribute to medication errors.

Medication errors are a major issue affecting patient safety in hospitals, which can create deadly consequences for patients. It is crucial to identify and analyzed medication errors so healthcare professionals can pinpoint why medication errors occur and provide insight into how to prevent or reduce them.