Medication Administration Errors

Keers (2013), conducted a systematic review which included 54 studies of English language publications and found evidence relating to the causes of medication administration errors within hospitals. Prescribing and administering drugs appeared to have the largest association with the greatest number of medication errors. Harm does not specifically have to be caused for medication errors to result. The most common type of unsafe medication error was found to be slips and lapses. Slips and lapses include misidentification of patient/medication, misreading labels, mental state, or forgetting to sign a medication order. The following were all other causes of medication administration errors found to complicate patient safety: knowledge and rule-based

mistakes, violations, managerial decisions, the patient themselves, policies and procedures, equipment complications, health and personality, inadequate training and experience, communication, supervision, workload, work environment, and medicine supply/storage. These causes demonstrate that staff is responsible for preparing and administering medication but are prone to making unsafe acts and that their errors are influenced by surrounding working conditions. Overall, limited evidence from the studies suggests the MAEs are influenced by multiple systems factors. However, the findings did conclude that the key to implementing a successful intervention to minimize medications errors is to understand how and why they occur. The best method for determining the prevalence of medication administration errors is by direct observation. Direct observation can identify the potential error, or factors associated with the error, which whom the person making the error may not recognize. Once this is understood the contributors to medication error can be reduced or eliminated.