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 that occurred at Independence Medical Center 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.

When I doing safety rounds, I noticed that there were two patients on the same floor and

directly opposite rooms with similar identifiers, B. Moore and B.R. Moore. The patients also had
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easily confusable birthdates: B. Moore’s was 8/11/05 and B. R. 11/8/05. After talking to the

charge nurse, I learned that scheduling was done such that different nurses were assigned to each

patient and notes were made in the patient charts. However, I received a call from the risk

manager later on informing me that a medication error had occurred. One of the nurses had

administered B. Moore with insulin yet the patient was non-diabetic and was not supposed to

receive insulin. The nurse had given the dose for B.R. Moore to B. Moore. This error was

attributed to patient identity in the ward.

Implications of not Addressing Threat

The medication error presents many adverse implications if it is not addressed. To

understand the importance of addressing medication errors in general, it is crucial to review the

safety imperative as proposed by the Institute for Healthcare Improvement and discussed by

various authors.

Health Safety Imperative

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.

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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 error in our

health center 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. Looking back at the error it is evident that poor

communication and coordination of care among nurses attending the two patients were the

causes of the incident. The imperative thus proposes the need for care teams which share

information effectively.

Evaluation of Risk

Furthermore, failure to address the medication error and other sources of errors at

Independence Medical Center 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.

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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

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.

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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

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

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

responsibility of all staff interacting with patients and their medications. My role as 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).

Therefore, I oversee the 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.

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The presence of a safety officer is crucial as evidenced in previous examples of

medication errors. In the medication error described by Da Silva and Krishnamurthy (2016), a

71-year-old patient received an antipsychotic drug (Navane) instead of hypertension medication

(Norvasc) for three months leading to physical and psychological harm. In this incident, medical

providers kept ignoring her worsening symptoms. Although the patient eventually recovered

when the error was corrected, the absence of a patient safety officer in this hospital led to the

lack of coordination in detecting and correcting medication errors. For instance, the safety officer

could have conducted routine medication reconciliations and the error would have been detected

earlier. This case is an example of the role of the patient safety officer in reducing medication

errors and their impacts and it shows that the officer is crucial to quality improvement.

In connection to the medication error I have to take several steps. The first responsibility

is to identify the sources of medication errors. A root-cause investigation of the Moore

medication error will be conducted under my supervision to determine what caused the error.

Nurses on duty during the time of error will be interviewed and schedule also reviewed.

Secondly, I will propose the best interventions to reduce the risk of errors. The immediate action

I took was to check on patient status and I am happy to report that they are recovering well. After

analysis of existing data and interviewing members involved, the next step is to recommend

actions to prevent future errors. I will then lead the implementation of a computerized physician

order entry (CPOE) system. 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.

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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

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 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 patient identification by including more pertinent information

such as additional patient identifiers. 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

medication reconciliation programmes on clinical outcomes at hospital transitions: a

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

Informatics Association, 24(2), 413-422.

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

StatPearls Publishing.

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

managing medication errors. Hospital pharmacy, 52(4), 308-315.

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

Economic impact of medication error: a systematic review. Pharmacoepidemiology and

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Da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: a patient

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