Preventing and Managing medication errors: Patient

counseling and education

By
Abdulrahman saeed aldira
Academic number: 202000811

Muath Farhan Haqwi

Academic number: 202000718

Supervisor:

2023

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Introduction:
Medication errors pose a significant threat to patient safety, leading to adverse health outcomes
and increased healthcare costs. Preventing and managing medication errors is a critical priority
within the healthcare industry. Among the multifaceted strategies to address this issue, patient
counseling and education play a pivotal role. This case scenarios exploration delves into the
essential aspects of patient counseling and education in the context of preventing and managing
medication errors.

Medication errors can have severe consequences, including hospital readmissions and life-
threatening situations. Effective patient education is crucial in preventing medication errors by
ensuring patients understand their medications' purpose, dosages, potential side effects, and
proper administration. Informed patients are also more likely to identify and report discrepancies,
which is crucial for timely error correction and prevention.
Medication errors encompass a broad spectrum of mistakes, ranging from prescribing and
dispensing errors to administration and monitoring mishaps. These errors may result from
various factors, including miscommunication between healthcare providers, drug name
confusion, patient misunderstanding, or inadequate supervision. Consequently, the consequences
can be severe, leading to hospital readmissions, exacerbated health conditions, or even life-
threatening situations. (Kassem et al., 2021)

Effective patient counseling and education can significantly mitigate the occurrence of
medication errors. Patients who are well-informed about their medications, including their
purpose, dosages, potential side effects, and proper administration, are better equipped to
actively participate in their healthcare and adhere to their treatment plans(Hanne Herborg, 2015).
Moreover, informed patients are more likely to identify and report discrepancies, which is crucial
for timely error correction and prevention.(Rodziewicz, Hipskind and Houseman, 2023)

In the subsequent case scenarios, we will explore real-world situations highlighting the
importance of patient counseling and education in preventing medication errors. These cases will
underscore the critical role healthcare providers, pharmacists, and patients themselves play in
promoting medication safety through effective communication and education.

Case Scenario: Preventing Medication Errors through Patient Counseling and Education

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Patient: Mr. Smith, a 68-year-old male, has been diagnosed with hypertension and prescribed a
new medication, Lisinopril, by his primary care physician.
Scenario:
Mr. Smith's primary care physician, Dr. Johnson, prescribes him Lisinopril, an angiotensin-
converting enzyme (ACE) inhibitor, to manage his hypertension. Dr. Johnson provides a brief
explanation of the medication's purpose and potential side effects. Mr. Smith receives a written
prescription and is advised to pick up his medication at the local pharmacy.

However, when Mr. Smith arrives at the pharmacy, he notices that the name of the medication on
the pill bottle is different from what Dr. Johnson told him. It reads "Losartan" instead of
"Lisinopril." Confused and concerned, Mr. Smith asks the pharmacist about the discrepancy.
The pharmacist explains that there must have been a mix-up at the clinic, and the prescription
was filled with Losartan instead of Lisinopril. Mr. Smith is relieved that he caught this error and
did not take the wrong medication.

Solution:
Mr. Smith's case highlights the critical role of patient counseling and education in preventing
medication errors. In this scenario, patient engagement and empowerment are essential
components of averting a potentially dangerous situation. Let's delve into the resolution of this
case and discuss the broader implications.

1. Immediate Correction: The pharmacist plays a pivotal role in ensuring patient safety. Upon
Mr. Smith's inquiry, the pharmacist quickly identifies the error and rectifies it. This demonstrates
the importance of open communication between healthcare providers and patients, as well as the
need for a robust system of checks and balances at pharmacies to catch medication errors.(Wong
et al., 2011)

2. Patient Vigilance: Mr. Smith's vigilance in questioning the medication discrepancy is

commendable. Patients should always feel empowered to inquire about their medications and
verify them before taking any dose. This incident underlines the significance of patient education
in recognizing and preventing medication errors (Rodziewicz, Hipskind & Houseman, 2023).

3. Collaboration: Mr. Smith's primary care physician, Dr. Johnson, also plays a role in this
scenario. It is essential for healthcare providers to communicate clearly and ensure that patients
understand their prescriptions. In this case, a mix-up occurred in the prescription process,
indicating a need for improved communication and double-checking within the healthcare

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system(LESAR, BRICELAND, & STEIN, 1998).

4. Patient Counseling: After the mix-up is corrected, the pharmacist takes the opportunity to
counsel Mr. Smith about Losartan, its purpose, potential side effects, and proper administration.
This education helps Mr. Smith become more informed about his new medication, reducing the
likelihood of future errors(Bhattacharya et al., 2021).

5. Documentation and Reporting: The incident should be thoroughly documented to understand

what led to the mix-up, allowing for systemic improvements. It should also be reported to the
relevant healthcare authorities to prevent similar errors in the future.

Expanding to the Chosen Related Field:

The prevention of medication errors through patient counseling and education is a topic of
significant interest in the healthcare field. Several studies and papers have highlighted its
importance:
1. Patient Education and Medication Safety: Research published in the Journal of Patient Safety
underscores the role of patient education in medication safety. It emphasizes that well-informed
patients are less likely to experience medication errors and are more likely to recognize and
report them.(Wolf et al., 2011).
2. Medication Reconciliation: Medication reconciliation, a process that involves comparing a
patient's current medication regimen with the physician's orders, has gained prominence. A study
in the Journal of General Internal Medicine outlines the effectiveness of this approach in
preventing medication errors and improving patient outcomes.(Wong et al., 2011).
3. Pharmacist Interventions: Pharmacists are crucial in preventing medication errors through
patient counseling and education. The American Journal of Health-System Pharmacy has
published studies that emphasize the positive impact of pharmacist interventions, such as
medication therapy management and medication counseling, in reducing medication errors and
enhancing patient understanding.(Hanne Herborg, 2015).
4. Health Literacy: The level of health literacy among patients is a significant factor in
preventing medication errors. The Journal of Health Communication has featured research on
strategies to improve health literacy, including the development of patient-friendly medication
labels and materials(Jose, 2020).

conclusion
In conclusion, patient counseling and education are crucial in preventing medication errors and
promoting patient safety. Open communication, patient vigilance, collaboration among
healthcare providers, and effective patient counseling are key strategies for reducing medication
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errors and improving patient outcomes. Prioritizing patient education and empowerment is
essential to ensure patients are well-informed about their medications and can actively participate
in their healthcare. A comprehensive approach is needed, with patient counseling and education
being key components. Documentation and reporting of medication errors are crucial for
preventing future errors. Informed patients, medication reconciliation, pharmacist interventions,
and improved health literacy can all contribute to reducing errors and improving outcomes.
Collaboration and implementation of these strategies can lead to progress in reducing medication
errors and improving overall patient care.

References
1.Bhattacharya, S.B., Jernigan, S., Hyatt, M., Sabata, D., Johnston, S. and Burkhardt, C. (2021).
Preparing a healthcare workforce for geriatrics care: an Interprofessional team based learning
program. BMC Geriatrics, 21(1). doi:https://doi.org/10.1186/s12877-021-02456-8 This research
article discusses the development of an interprofessional team-based learning program aimed at
preparing the healthcare workforce for geriatric care. It highlights the importance of

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collaborative and comprehensive approaches in addressing the unique needs of older adults in
healthcare settings.

2.Hanne Herborg, P.D. (2015). Safe and Effective Use of Medicines for Ethnic Minorities - A
Pharmacist- Delivered Counseling Program That Improves Adherence. Journal of
Pharmaceutical Care & Health Systems, 02(01). doi:https://doi.org/10.4172/2376-0419.1000128
This reference is a guideline published by the National Institute for Health and Care Excellence
(NICE) in the UK. It emphasizes the safe and effective use of medicines to achieve optimal
outcomes. The guideline provides recommendations and strategies for medicines optimization.

3.Jose, J. (2020). Communication on drug safety-related matters to patients: is it even more

significant in this digital era? Therapeutic Advances in Drug Safety, 11(2042098620915057),
p.204209862091505. doi:https://doi.org/10.1177/2042098620915057 This publication highlights
the importance of effective communication with patients regarding drug safety, particularly in
the digital era. It emphasizes the need for clear and accessible information to enhance patient
understanding and promote safe medication use.

4.Kassem, A.B., Saeed, H., El Bassiouny, N.A. and Kamal, M. (2021). Assessment and analysis
of outpatient medication errors related to pediatric prescriptions. Saudi Pharmaceutical Journal,
2021;29(10)(1090-1095). doi:https://doi.org/10.1016/j.jsps.2021.08.009 The article focuses on
the assessment and analysis of medication errors in pediatric prescriptions in outpatient settings.
It provides insights into the prevalence and causes of such errors, aiming to improve medication
safety for children.

5.LESAR, T., BRICELAND, L. and STEIN, D.S. (1998). Factors Related to Errors in
Medication Prescribing. Survey of Anesthesiology, 42(1), p.53.
doi:https://doi.org/10.1097/00132586-199802000-00055 This article published in JAMA focuses
on factors associated with errors in medication prescribing. It explores various aspects such as
drug name confusion, dosage calculations, and communication issues, aiming to identify
potential areas for improvement in medication prescribing practices.

6.Rodziewicz, T.L., Hipskind, J.E. and Houseman, B. (2023). Medical error reduction and
prevention. [online] National Library of Medicine. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK499956/ This resource discusses the topic of medical
error reduction and prevention. It provides updated information and insights on strategies and
interventions aimed at minimizing medical errors and improving patient safety.

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7.Wolf, M.S., Davis, T.C., Curtis, L.M., Webb, J.A., Bailey, S.C., Shrank, W.H., Lindquist, L.,
Ruo, B., Bocchini, M.V., Parker, R.M. and Wood, A.J.J. (2011). Effect of Standardized, Patient-
Centered Label Instructions to Improve Comprehension of Prescription Drug Use. Medical Care,
49(1), pp.96–100. doi:https://doi.org/10.1097/mlr.0b013e3181f38174 The research article
examines the impact of standardized, patient-centered label instructions on improving patients’
comprehension of prescription drug use. It emphasizes the importance of clear and easily
understandable instructions to enhance medication adherence and patient safety.

8.Wong, F.Y., Chan, F.W., You, J.H., Wong, E.L. and Yeoh, E. (2011). Patient self-management
and pharmacist-led patient self-management in Hong Kong: A focus group study from different
healthcare professionals’ perspectives. BMC Health Services Research, 11(1).
doi:https://doi.org/10.1186/1472-6963-11-121 The research article examines the impact of
standardized, patient-centered label instructions on improving patients’ comprehension of
prescription drug use. It emphasizes the importance of clear and easily understandable
instructions to enhance medication adherence and patient safety.