Every health care professional should provide the best quality care and maintain patient safety. Previous assessment consists of a brief overview and library research regarding the issue interfering with the quality of care and safety of patient – medication errors (MEs). This paper aims to explore this problem in-depth: explain causes and context for MEs, populations affected, and potential solutions. The most threatening feature about this problem is that MEs can occur at any stage of medication use, and there is no single correct strategy to prevent them. However, in most cases, MEs are made by medical staff, and the paramount solution is to improve education and implement special training.
Elements of the Problem/Issue
MEs can occur throughout the medication use process, which implies that errors occur during prescribing, documenting, dispensing, administering, or other stages in-between. Mulac et al. (2020) discovered that the most vulnerable stages were prescribing and administering: 68% and 24% of MEs respectively occurred during these stages (p. 57). The medication use process involves diverse specialists and assumes that medication-related errors can be made by nurses, pharmacists, physicians, or even patients and caregivers. Therefore, there are many factors and situations potentially leading to the occurrence of such mistakes.
Prescription errors usually occur in case of inadequate calculation resulting in a wrong dose or prescribing incorrect drugs due to similarity of medication names. An example is a health care professional prescribes adult dosage when treating a child. MEs related to documentation may occur because of poor writing, missed patient information, usage of abbreviations, or failure to record new conditions or symptoms. An example is a healthcare professional using the abbreviation “D / C” for discharge, but other specialists or patients identify it as discontinuing medications. Dispensing errors occur due to wrong medication or dose, miscalculating, and failure to recognize contraindications or medication interactions. An example is dispensing a medication to which the patient is allergic. MEs related to administration frequently take place when a health care professional fails to follow Five Rights rule. An example is a nurse’s failure to verify a patient’s two identifiers, leading to administering a drug to the wrong person.
I am interested in solving this problem since I have committed such mistakes and witnessed MEs made by other medical staff. Medication-related errors are life-threatening and interfere with patient safety, being “the third leading cause of death” in the United States (Davis & Coviello, 2020, p. 273). As a health care professional, I need to provide patients with appropriate care and do no harm. I want to minimize the occurrence of such events and improve patient safety and health care quality. I should be aware of this issue, factors contributing to MEs, and ways to prevent them. Moreover, considering the second-victim phenomenon, I also risk suffering from mental problems associated with committing such mistakes (Treiber & Jones, 2018). Sufficient knowledge and skills are crucial within every health care professional’s experience and practice.
Context for Medication Errors
MEs take place in every health care setting and can be considered in a variety of contexts. Medical staff may be distracted while prescribing, preparing, or administering a drug by conversations, urgent calls, or acute situations. Inattentiveness of health care professionals can be associated with high workload, multitasking, and high patient flow (Bucknall et al., 2019). Pharmaceutical companies, providers, drug manufacturers may make production errors, proceed with improper medication storage, or supply expired drugs.
Another context of MEs’ occurrence is a flaw of competence or skill and insufficient drug knowledge. Neglect of interdisciplinary consulting while being unsure about medication leads to the emergence of MEs as well. Other common circumstances are misunderstandings related to abbreviations or poor handwriting, similar drug names, alike packaging, as well as ignoring recommendations, rules, and protocols for medication usage. Poor communication with a patient can also result in ME due to missing patient information, failure to attain medical and allergy histories. Health care professionals may lack knowledge that patient tends to suffer from side effects or takes multiple medications.
Populations Affected by Medication Errors
No patient is immune from medication-related errors; however, some populations are more frequently affected by this issue. Mulac et al. (2020) state that “50% of all errors were associated with patients aged over 65 years” because elderly people tend to take multiple medications (p. 60). According to their research, another vulnerable population is children, particularly infants (Mulac et al., 2020). The risk of developing ME is also increased in allergy sufferers and people with certain health conditions.
A compound approach that focuses on medical staff education, technological innovations, interdisciplinary and team cooperation, packaging improvements, and patient training can reduce and prevent MEs. The leading strategy is computerizing and automatizing the process of medication use. It includes the usage of computers, electronic health records, bar-codes, and medication dispense machines. Risør et al. (2018) implemented two automated medication systems and, after researching, concluded that “technological interventions in the MA process can reduce the occurrence of medication errors” (p. 464). According to Martyn et al. (2019), managing workflow contributes to safe and prompt medication administration. Martyn and Paliadelis (2019) highlighted key points in providing medication safety that included appropriate fruitful teamwork. Thus, managing the working environment and flow as well as productive teamwork involving various specialists is another solution to prevent MEs.
Considering widespread confusion caused by the similarity of drugs names and packaging, eliminating this factor appears essential. Shao et al. (2018) conducted research and found an effective strategy for selecting similar drugs by labeling them with different colors. Kim et al. (2018), Martyn et al. (2019), and Buchnall et al. (2019) highlight the importance of involving patients in the medication use process. Patient-centered strategies imply providing patients with sufficient drug information, training, and family engagement. Nonetheless, either of mentioned approaches can replace health care professionals’ education, training, skills, and experience. A potential solution implies the development of new teaching strategies for medical staff.
The paramount solution is to improve educational strategies, implement special training and enhance the skills and competencies of health care professionals. Nonetheless, it is impossible to create a unified curriculum for all medical, nursing, and pharmacist students due to differences in roles in the medication use process. According to Mulac et al. (2020), 62% of MEs are reported by nurses, and 68% of medication-related errors occur during the administration stage (p.7). Thus, teaching strategies should primarily target nurses and nursing students, highlighting safe medication administration.
No ethical implications are associated with the implementation of this solution. On the contrary, it aims to enhance care and safety quality, striving for more benefits and less harm for patients. Beyond intensive pharmaceutical training, a strong emphasis should be set on teaching correct calculations and measurements and learning in situations that simulate real-life conditions in various clinical areas (Latimer et al., 2017; Treiber & Jones, 2018). The studies of Martyn and Paliadelis (2019), Martyn et al. (2019), and Davis and Coviello (2020) argue that the curriculum for nurses should provide more broad information than the Five Rights concept and become more patient-orienteered. Thus, this approach does not interfere with ethical principles and is more ethically correct than, for example, technological innovation.
MEs are crucial for the quality of care and safety, resulting in minor or severe up to death harm for the patient. Nonetheless, MEs are preventable events, and it is essential to find the best strategies for their reduction. Potential solutions include medical staff education, technological innovations, interdisciplinary and team cooperation, packaging improvements, and patient training. Improved teaching strategies appear the preferable solution since this approach does not interfere with ethical principles.
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