Understanding Medication Errors: Causes And Prevention

Causes of Medication Error

Health indicators are measures that are reported regularly so that they can give relevant information’s about a population health. An indicator can help in information comparison and to track progress and performance. When an indicator can be be pointed out there should be always a plans on how to improve the health care in the health care settings. When plans are usually created and executed there are measures that will show that there is progress or not so that if there are no progress more plans can always be set up to boost the later plans

Medication error is any preventable event the may lead to misuse medication or the patient being affected while medication is still in the control of the health care professionals (Aydon, et al 2014). This events can always be related health care products, health care professionals, rules followed and use. These ways may include order of communication, distribution administration and others. Medication error can occur at any point of medication.

First there are some types of medication errors that are very common. They include wrong dosage and infusion rate. Wrong dosage is any incorrect administration of any medication. This mistakes include mistake in dosage, way of administration and unable to know the correct drug. Infusion rate is the desired rate of administering a given drug to do a certain dose believed to effective therapeutically.

The most common cause is the use of abbreviation in naming drugs instead of using full names. Connection with this is the similar naming of drugs. The main reason for this is that (omit) lack of pharmaceutical knowledge. When there is this confusion, this means a patient can always be given a drug that cannot help him or her and in the cause it can always be harmful to the patient’s health. The area mostly affected by this effect is the nursing department due to lack of understanding to some of these nurses.

Incomplete patient information is another cause of medication error. This involves lacking all the information about the patient which include the medicines that the patient I allergic to, lab reports on the patient and earlier diagnoses. One of the reason the health workers can fail to get all the information is because some are ignorant when the patient wants to always give the information they jump into conclusions. Another reason is that the patient may fear or shy while keeping to himself some personal information.

Another cause of error in medication is distraction and environment (Carnes, et al 2015). In any area of work where serious things can ways be done, distraction such as noise should always be at its least. When a nurse (omit) can be distracted he or she can read a drug name wrong when administering. This is not insignificant, when a wrong dose can be administered to a patient, if it is harmful it can harm the patient. A health worker who is always overworked can make medication errors out of exhaustion. In addition poor lighting and other environmental factors can lead to distractions.

London Protocol

Memory lapses and are also a major cause (Carnes, et al 2015). Memory lapses is when a health worker knows that a patient is allergic as an example but forgets. When a health worker forgets he or she will move on and give a wrong dosage which in return will mostly harm the patient after use. Health workers should always be very serious on these and be clearly sure before giving any dosage.

According to the latest survey recorded 53 increase in issues of medication error. Medication error can affect everyone and does not exclude. Both young and old and women and men. This kind of indicator can occur anywhere and anytime. If one is not attended at a very fast rate than it can lead to also lead to death if inappropriate dosage is always administered. The consequences of medication errors are dangerous. It can also lead to worsening of the patient health. These shows that in time of occurrence it should always be dealt with to avoid other greater effects.

The main reason to choose this type of indicator is because it does not only affects a country like Australia but also to the rest of the word. In order to see an improvement one has to know the causes of a certain problem than finds the immediate solution to the problem. The above causes of medication error avoided and tried to be prevented can lead to decrease in the occurrence of medication errors. Since this is health care indicator that can affect everyone that is the main reason to study it.

When a problem is solved there can be either an improvement or no improvement (Gilbar, et al 2014). This can be done using some measures which included:

Process measure. This is how well one is performing core processes in terms of medication. It helps in determining the variation in carrying them out which can lead to undesirable outcomes or harm. Examples of these processes include some pharmacy profiles without allergy information in accordance to new admission orders.

Structure measure. They asses the culture, values and leadership of an organization. It’s not task oriented compared to process measures. Examples include number of error reports received and others

Outcome measures. They assess whether ones efforts to improve medication is successful. Mostly errors are always used to measure medication safety. 

Balancing measures. This is used to make sure a change in one area of a system will not affect another part in the same system. Medication measure is not easy but as long as there is a good plan then and a team to do the work then the job will be effective

Medication measure is not easy but as long as there is a good plan then and a team to do the work then the job will be effective.

One important plan is to bring professional health workers into the health centers (Graudins, et al 2016). This will help in the way that a health worker cannot confuse two different kind of drugs with almost similar names. They will also be able to give the correct naming in the dosage and not abbreviation. Since that is a plan and the doing, one has to check if the plan is working. One can use outcome measures among others. If the number of medication errors has cut then the plan is well and working but if it has less or no impact then the method has to be adjusted

Measures to Improve Medication Safety

A health center can be said to be a very quiet place and this should always be taken seriously (Heneka, et al 2015). The plan is to remove any kind of distraction mostly noise. This distractions have a very big negative effects. The main one is that the health worker concentration will not concentrate on what he or he will be doing hence leading to mistakes. Distractions can make a health worker also forgets about very important details and end up doing mistakes. The action is to have laws and policies on reducing distractions like noise. Then there is the measure of the outcome. If the method is good then the system is effective but if it isn’t working then adjustments are always done immediately.

Ensuring the rights of medication are always followed (Hewitt, et al 2015). This was a plan but action are less. Health workers should work on this ensuring that there is correct medication prescribed to the correct patient. That is in the correct dosage, correct route and at the correct time also. Then this method can be checked and measured to see its effectives. If it doesn’t work well effectively then there should always be a new system or some adjustments.

Double check and also triple check is also a good plan (Holmström, et al 2015). This is a plan where a health worker reviews all new orders and each patient order is noted and transcribed correctly according to the physician and the medication administration order. This will really help because there will almost no confusion. This method is checked and measured after a period of time and if it is good it is adapted again and if it is not it is adjusted. 

Another plan which seems to be more effective is the plan of documenting everything (Hutchinson, et al 2015). This includes proper labelling, documents that are legible and effective recording of the administered medications. In case of no documentation then errors will be a big friend. In case there is poor medication different medications will be administered to different people hence a big error. After a period the method I checked and measured. If the method is working it is absorbed if not it is adjusted.

Another plan is by ensuring proper storage of medications for better efficiency (Manias, et al 2014). When drugs are stored in given strategic positions then it will be very hard for one to confuse. Different kind of drug will be situated in given point different from the others. This can help in increasing medication safety. If the method is found to be effective is taken but if it is less or never effective is adjusted

Plan to health workers to consider having a drug guide at all times (Mitchell, et al 2015). It can be printed or electronic since it is for personal use. This guide can be used in providing various information’s on different areas which include therapeutic class, generic names and others. Once the method is checked, if it is of less or no positive impact it is adjusted but if it is working it is kept in use.

There is also the follow of proper medication and procedures of reconciliation (Naunton, et al 2015). Hospitals have put certain mechanism at place to ensure smooth flow of patients from one unit to the other. They must review and verify the medication for the correct patient, correct dosage, route and time against the transfer order. Some medication record are easy to verify but it is mandatory for them to be verified. If this method works effectively it is adapted but if it fails it can be adjusted. Having another physician reading out orders and using of name alerts (Ohashi, et al 2014). This is a very important plan but easy. Once it is implemented, it means that orders can be read out loud by another physician while the other executes the order to decrease errors. The other physician will be able to concentrate and give the dosage very well and in case of any confusion he or she can ask and repeat the procedure Name alerts are used where the names are sounding the same and this alerts should be in front of MAR to cut errors. When such a method works, it is adapted but when it fails adjustments are done or leave the plan.

To make sure there is patient safety one should learn from the errors available to come up with ideas on how to ensure a patient more secure by solving the errors (Parry, et al 2015). In terms of patient experience, in 2012 there were 107 serious medical errors in Australia which lead to deaths and disability in these people (Omura, et al 2015). There has been a decrease of 10% in the five years to 2012. This should always be taken seriously to reduce this error because some can be underestimated

As a patient the first person to know if there is a medication error will be the patient (Rajanayagam, et al 2015). When one gets some signs and side effects which were not there before one started taking the medicine then one can tell there is a problem in the medication. When ones notice it is her or his role to go back to the health professional and explain the details of the new experience to solve all these before it worsens. Before going to the health center the person should first stop taking those medicines from that point onwards until one is clear and sure they are the right medications.

The person as a patient should also have more than one physician not just being hooked in one health professional (Ranchon, et al 2015). This cam help greatly because once a certain dosage can be approved by one physician and one is not really clear about it one can verify from another physician of another field. One can also compare what the both professionals say about the disease. If they say a common thing then one is sure but if they differ then another solution must be thought of.

The health experts should always be well-educated and skilled for them to work in a health facility (Roughead, et al 2016). If a physician is not sure of what he or she should do then the patient’s lives are at risk. Before a health professional comes to work he or she should have proper education and a good and extensive internship to give him or her better knowledge on handling people’s lives. The reason for this is because they will find it difficult to confuse a certain drugs with the other, they will be able to give dosage correctly in a correct route as per the time in hand. Health professionals should dedicate themselves on education the public (Sahay, et al 2015).

Education is always the best weapon since an educated person will fail to do something out of ignorance. The experts should form education centers where the community can be taught how to find the immediate symptoms of medication error and how to act responsibly incase this happens. The higher health professionals can also educate the health expertise at low levels on how to reduce medication errors toward the patients. The health professionals should make sure that the rules governing medication are strictly followed (Samsiah, et al 2016). When these rules can be adhered to to, this means that there will be giving of the patient the correct dosage, at the correct time, using the correct ways. In case a health expert doesn’t follow these rules serious actions should always be taken into place immediately.

• The public should have clear knowledge on the causes, prevention and dangers of medication errors.
• The health centers available should have well experienced health professionals.
• The issue of medication error should never be underestimated under any circumstance because it is dangerous too.
• There should a way to measure if there are improvements or not in order to know is the method’s is effective or should it be modified.
• Both the individual and the health leaders should work together to ensure that the health care has improved.

Conclusion

In conclusion, every member of the society and health professionals should always be well conversant with the causes leading to medication error. When they have knowledge on that, they will be able to prevent it from occurring. The public have to be taught on this issue and on the other side the public should take it very serious. When the community is aware of the medication error and details about it, the can always be able to act very fast while they wait for treatment hence saving many lives. One side can’t work alone, both an individual and the health workers should work as one to make sure this area is well attended to.

References 

Aydon, L., Hauck, Y.L., Murdoch, J. and Foster, C., 2014. Developing a culture of nursing research in neonatal clinical care in Western Australia. Neonatal, Paediatric & Child Health Nursing, 17(2), p.2.

Carnes, D.M., 2015. Getting the truth: a qualitative comparative analysis of rural nurses’ attitude to safety climate and their views of reporting a hypothetical medication error (Doctoral dissertation, University of Tasmania).

Fanning, L., Jones, N. and Manias, E., 2015. Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before?and?after study. Journal of evaluation in clinical practice.

Gilbar, P.J., 2014. Intrathecal chemotherapy: potential for medication error. Cancer nursing, 37(4), pp.299-309.

Graudins, L.V., Treseder, R., Hui, C., Samuel, T.L. and Dooley, M.J., 2016. A proactive quality strategy to decrease the risk of error associated with medication procurement. Journal of Pharmacy Practice and Research, 46(2), pp.145-151.

Heneka, N., Phillips, J.L., Rowett, D. and Shaw, T., 2015. Identifying Opioid Medication Error Types, Incidence And Patient Impact In Adult Oncology And Palliative Care Settings: A Systematic Review. Asia-pacific Journal of Clinical Oncology, 11, p.128.

Hewitt, J., Tower, M. and Latimer, S., 2015. An education intervention to improve nursing students’ understanding of medication safety. Nurse education in practice, 15(1), pp.17-21.

Holmström, A.R., Laaksonen, R. and Airaksinen, M., 2015. How to make medication error reporting systems work–Factors associated with their successful development and implementation. Health Policy, 119(8), pp.1046-1054.

Hutchinson, A.M., Sales, A.E., Brotto, V. and Bucknall, T.K., 2015. Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol. Implementation Science, 10(1), p.70.

Manias, E., Kinney, S., Cranswick, N. and Williams, A., 2014. Medication errors in hospitalised children. Journal of paediatrics and child health, 50(1), pp.71-77.

Mitchell, R.J., Harvey, L.A., Brodaty, H., Draper, B. and Close, J.C., 2015. Dementia and intentional and unintentional poisoning in older people: a 10 year review of hospitalization records in New South Wales, Australia. International psychogeriatrics, 27(11), pp.1757-1768.

Naunton, M., Gardiner, H.R. and Kyle, G., 2015. Look-alike, sound-alike medication errors: a novel case concerning a slow-Na, slow-K prescribing error. International medical case reports journal, 8, p.51.

Ohashi, K., Dalleur, O., Dykes, P.C. and Bates, D.W., 2014. Benefits and risks of using smart pumps to reduce medication error rates: a systematic review. Drug safety, 37(12), pp.1011-1020.

Omura, M., Levett?Jones, T., Stone, T.E., Maguire, J. and Lapkin, S., 2015. Measuring the impact of an interprofessional multimedia learning resource on Japanese nurses and nursing students using the Theory of Planned Behavior Medication Safety Questionnaire. Nursing & health sciences, 17(4), pp.500-506.

Parry, A.M., Barriball, K.L. and While, A.E., 2015. Factors contributing to Registered Nurse medication administration error: A narrative review. International journal of nursing studies, 52(1), pp.403-420.

Rajanayagam, J., Bishop, J.R., Lewindon, P.J. and Evans, H.M., 2015. Paracetamol-associated acute liver failure in Australian and New Zealand children: high rate of medication errors. Archives of disease in childhood, 100(1), pp.77-80.

Ranchon, F., You, B., Salles, G., Vantard, N., Schwiertz, V., Gourc, C., Gauthier, N., Guédat, M.G., Souquet, P.J., Freyer, G. and Trillet-Lenoir, V., 2013. Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences. Chemotherapy, 59(5), pp.330-337.

Roughead, E.E., Semple, S.J. and Rosenfeld, E., 2016. The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia. International journal of evidence-based healthcare, 14(Medication Safety Issue: 3), pp.113-122.

Sahay, A., Hutchinson, M. and East, L., 2015. Exploring the influence of workplace supports and relationships on safe medication practice: A pilot study of Australian graduate nurses. Nurse education today, 35(5), pp.e21-e26.

Samsiah, A., Othman, N., Jamshed, S., Hassali, M.A. and Wan-Mohaina, W.M., 2016. Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012). European journal of clinical pharmacology, 72(12), pp.1515-1524.