Running head: REDUCTION OF MEDICATION ERRORS 1

Reduction of Medication Errors

Name

Institution
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Reduction of Medication Errors

Patient safety is a priority of healthcare and the focus of many nurses and non-nursing

staff is to reduce the threats that patients face in the healthcare systems. One of the common

causes of patient harm is medication errors that may lead to various outcomes ranging from mild

reaction to patient death. Reduction of medication errors is essential to quality improvement in

healthcare systems. Continuous quality focuses on continuously improving the level of safety

that patients in the healthcare organizations enjoy. Patient safety is not only important for patient

outcomes but also the reputation of the healthcare organization and motivation of staff. This

paper reviews a medication error scenario and discusses the necessary approach to enhancing

patient safety in the healthcare organization.

Potential Threat to Patient Safety

The selected scenario is the occurrence of an adverse event and near misses due to patient

medication errors in the healthcare system. Medication errors can be described as “any

preventable event that may cause or lead to inappropriate medication use or patient harm while

the medication is in the control of the healthcare professional, patient, or consumer” (qtd. In

Polnariev, 2014). The selected issue occurred in the Vila Health Clinic and was a near miss event

whereby the safety of the patient was compromised. The mix up of medications leading to

administration of the wrong medication for a patient presents potential threat to the patient’s

safety since reactions and adverse events may be experienced due to the incident. Reduction of

medication errors is a necessary step towards boosting the safety of patients in Vila Health and

other healthcare organization as it reduces the risk of adverse events caused by this medication.

Health Safety Imperative

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Health safety is a core nursing imperative that can be used in addressing medication

errors in the healthcare organization. Professionals have identified the need for enhancing patient

safety in healthcare settings to protect both the patient and nursing staff. According to Kalender,

Tozan, and Vayvay (2020), medical errors kill between 44,000 and 98,000 patients each year and

healthcare providers experience the highest rates of nonfatal workplace injuries among all

professions. These statistics show that more education and focus on patient safety are needed in

healthcare settings today. The health safety imperative aligns with the reduction in medication

errors to enhance the safety of patients in the healthcare system by reducing adverse drug

reactions, adverse events, and near misses.

While significant progress has been made in reducing medication errors, the health safety

imperative endorses several principles in dealing with healthcare safety problems. One of the

most relevant to medication errors is the principle of encouraging transparency in disclosing

errors and quality problems (Hassan, 2018). This principle applies to the medication errors

problem by highlighting the need to encourage reporting behavior and avoid victimization of

staff who are involved. Moreover, the imperative suggests that the integration of care across

teams and disciplines may increase the safety of patients by reducing the sources of medication

errors (Hassan, 2018). The principle is based on the need for care coordination as an effective

approach to medication error reduction. Patient safety imperative implies that medication errors

may be minimized if a culture of safety and transparency in reporting as well as collaborative

interdisciplinary teams are effective interventions for reducing medication errors and their

consequences on patient safety in the healthcare organization.

Evaluation of Risk
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Failure to address medication errors in the healthcare organization presents a huge risk to

patients. The consequences of medication errors vary from no effects to death of the patient. In

the vast cases, patients will develop a negative reaction which may be identified in time to

reduce the risk to health. For instance, a patient who reacts allergically may develop the

symptoms and after stopping the medication and seeing a physician, the symptoms may be put

under control. In other instances, medication errors may lead to increased length of hospital stay

(Prgomet et al., 2017). This may be due to the impact on patient health and sometimes the

development of a new condition due to the error. Failure to address medication errors, therefore,

increases the likelihood of poor health outcomes, extended hospital stay, and risk of death.

In addition to effects on patients, employees and the organization may also be affected by

the failure to address the issue. The main risk is litigation due to patient negligence. The

attending care provider and the healthcare organization are answerable to charges brought

against them in a court of law by a patient whose health is affected by their failure to prevent

adverse events due to medication errors (Walsh et al., 2017). Such cases lead to loss of money

and also a tarnished reputation and loss of employment. In addition, practitioners who are

involved in such errors may suffer extreme guilt and shame which is harmful to their mental

health and their productivity. For example, in 2011, a nurse committed suicide after realizing that

she overdosed a baby with 10 times calcium chloride leading to her death (Aleccia, 2011).

Failure to address the sources of medication errors and their impact on patients and staff may

thus lead to fatal outcomes in the employees who are answerable for the errors.

Regulatory Agencies’ Role

The regulatory agency that is in charge of patient safety is The Joint Commission. The

commission offers patient safety goals and encourages consistency and commitment towards
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achieving the best possible care for patients. Among the commissions safety goals, identification

of patient safety risks, improving communication, using medications correctly, and labelling all

medications are the main goals associated with the prevention of medication errors (Rodziewicz

& Hipskind, 2020). Identification of safety risks in preventing medication errors can be done

through root cause analyses to determine the frequent causes of errors. Moreover, improvement

in communication can be implemented using coordination of care and platforms that encourage

collaborative work among staff. The use of medications correctly and labelling are approaches

directly related to how the care provider handles the medication in the healthcare organization.

These goals should be implemented to reduce the risk of medication errors.

Moreover, The Joint Commission has an impact on medication error reduction processes

in the healthcare organization. For example, when a sentinel event occurs, the commission

expects that it is reported by member agencies (Rodziewicz & Hipskind, 2020). The healthcare

organization, therefore, must implement relevant reporting mechanisms for dealing with the

occurrence of such events. Moreover, the commission requires that root-cause investigations are

conducted to determine the causes of sentinel events (Rodziewicz & Hipskind, 2020). For

example, when a physician prescribes wrong medication to a patient leading to serious injury or

death, the case has to be reported to the commission and root-cause analysis conducted to

determine the next steps. The competence of the physician may be evaluated to determine the

needs for training or disciplinary action that may be required. The Joint Commission requires

effective monitoring, investigations, and reporting of sentinel events that arise from medication

errors.

Patient Safety Officer’s Role

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The organization’s full commitment to patient safety includes the involvement of a

patient safety officer in the reduction of medication errors. Medication safety is a fundamental

responsibility of all staff interacting with patients and their medications. The role of the patient

safety officer is to reduce, with the aim of eliminating medical errors in the healthcare

organization by identifying problems and recommending solutions (Rogers et al., 2017). The

officer, therefore, is in charge of identification of the sources of medication errors through root-

cause analysis and the implementation of interventions to reduce the risk of those errors. The

officer is thus the clinical champion in proposing and implementing the required programs for

improvement of patient safety.

The patient safety officer has several responsibilities in improving care to reduce

medication errors. The first responsibility is to identify the sources of medication errors. They

may use archival data to highlight the units where medication errors occurred and the factors that

attributed to them. Secondly, the safety officer must evaluate and propose the best interventions

to reduce the risk of errors. After analysis of existing data, the officer may conclude that poor

care coordination leads to medication errors. The next step is to come up with recommendations

to be presented to the healthcare organization leadership for approval and implementation. A

recommendation may be the routine reconciliation of patient medications. The officer then

assembles the interdisciplinary team and guides it towards improved quality. The patient safety

officer is thus central to the entire process of determining sources of safety problems, drafting

solutions, and implementing programs to improve the status of patient safety.

Recommendations

The patient safety officer advances several recommendations to reduce the risk of

medication errors and adverse events in the healthcare system. The first step of the quality
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improvement process is to conduct thorough analysis of the common causes of medication errors

in the organization. Archival data and root-cause analyses highlight the factors surrounding

medication error events. This data can be reviewed to establish the main causes of errors in the

healthcare organization. The second step will be the implementation of weekly medication

reconciliation for patients with the collaboration of nurses and pharmacists. The inclusion of

pharmacists in the reconciliation process enhances the success of the reconciliation process in

reducing risk of medication errors (Mekonnen, McLachlan, & Jo-anne, 2016). Therefore, the

interdisciplinary team will be brought together for weekly medication reconciliation. The

reconciliation will involve patients and patients’ family members.

In addition to cause analysis and reconciliation, the hospital will implement a

computerized physician order entry (CPOE) system which will be accessible to physicians and

attending nurses and pharmacists for enhanced care coordination. Majority of medical errors

occur due to poor coordination of care among the professionals attending patients (Prgomet et

al., 2017). The CPOE will provide a platform whereby patient information is easily accessible to

all staff members who need it. The CPOE system will reduce errors such as ones emanating from

illegible writing by physicians. It will also enhance the professionals’ access to patient records

for medication reconciliation and improved accuracy of prescriptions and medication

administration. For example, ability of a nurse to access the patient’s drug interactions on the

CPOE system will increase safety of the patient. The safety officer will oversee the

implementation of the recommendations in the healthcare organization.

Conclusion

Patient safety requires keen consideration of sources of medication errors and a dedicated

program to reduce those errors. The patient safety officer’s role is in identifying safety issues,
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proposing recommendations for improvement, and guiding efforts in quality improvement. The

provided scenario of medication error risks the life of the patient and the safety of staff and

organization as well. The safety officer should conduct root-cause analyses to pinpoint common

sources of errors and address them using the stipulated recommendations for best outcomes in

the healthcare organization. Medication errors are a major cause of death and extended hospital

stay. It is imperative to address them as a safety issue in the commitment of healthcare

organizations towards continuous quality of care.

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References

Aleccia, N. (2011, Jun. 27). Nurse’s suicide highlights twin tragedies of medical errors. NBC

News. http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-

highlights-twin-tragedies-medical-errors/#.X1oazmgzaM9

Hassan, I. (2018). Avoiding medication errors through effective communication in healthcare

environment. Movement, Health & Exercise, 7(1), 113-126.

Kalender, Z. T., Tozan, H., & Vayvay, O. (2020, September). Prioritization of Medical Errors in

Patient Safety Management: Framework Using Interval-Valued Intuitionistic Fuzzy Sets.

In Healthcare (Vol. 8, No. 3, p. 265). Multidisciplinary Digital Publishing Institute.

Mekonnen, A. B., McLachlan, A. J., & Jo-anne, E. B. (2016). Effectiveness of pharmacist-led

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systematic review and meta-analysis. BMJ open, 6(2).

Polnariev, A. (2014). The Medication Error Prioritization System (MEPS): a novel tool in

medication safety. Pharmacy and Therapeutics, 39(6), 443.

Prgomet, M., Li, L., Niazkhani, Z., Georgiou, A., & Westbrook, J. I. (2017). Impact of

commercial computerized provider order entry (CPOE) and clinical decision support

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units: a systematic review and meta-analysis. Journal of the American Medical

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Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. In StatPearls [Internet].

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Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A just culture approach to

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Walsh, E. K., Hansen, C. R., Sahm, L. J., Kearney, P. M., Doherty, E., & Bradley, C. P. (2017).

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