Medication Errors Research Paper

Medication Errors in an Acute Setting

Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.

Poor order transcriptions and documentation of orders given by doctors to nurses whether it’s verbal, written or over

the phone could cause life threatening injuries, serious adverse reactions, and anaphylaxis shock , and death when the wrong amount is given to the wrong patient or even to the right patient. Due to the work load of many nurses they are prone for more errors, because they do not always take the time needed to clarify orders and sometimes assume to know what the doctor was trying to say or write . Unfortunately, doctors and nurses are not the only ones included in patient medication errors pharmacist are also involved, because they can dispense the wrong dose or wrong medication to the patient and the nurse is not paying attention when administering the medication the nurse will be the one liable if something were too happen to the patient. Polypharmacy also makes it harder to keep track of drugs side effects and medication interactions because of all the different mixtures with medications. Other medication errors can happen when doctors and nurses misread or misplace points and zeros.
According, to an article by, Applied Nursing Research, environmental factors can also contribute to medication errors due to inadequate lighting at the nursing station, and for that reason orders are not being transcribe properly, decrease light in the medication room can cause a nurse to misread the labels, and the distance of the nursing station and the level of distraction on the unit can all lead to medication errors.

Milani, Oleck and Lavie reported that Medical errors are the eighth leading cause of death in the hospitals. About 44,000 to 98,000 people die each year from adverse effects from medication errors, 1 million annually die in

hospitals.
Researchers has found that error detection is the first step to detecting medication errors.

Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.

Many were reprimanded by verbal or documentation measures which was placed in their personnel files. One sixth of the hospitals had no documentation or disciplinary action in place. One fourth were either suspended or terminated as their form of disciplinary action, and legal action was never used. Many of the hospitals listed medication errors which had caused harm (42%), and death (40%) in personnel files. However, 34% of the other hospitals did not put any form of documentation of medication errors in any personnel file. There were a difference of three fourths between errors caught and not caught before the medication leaves the pharmacy and reaches the patient.
The FDA has enhanced its efforts to reducing medication errors by giving more money to drug safety and preventing. Close monitoring are being done to prevent medication errors before a and after the drug reaches the market. Bar code label rule has proven to be effective after the VA hospital in Topeka reported a drop of medication error of 86% over a nine year period. Upon enter into the hospital patient receives a bar-coded identification wristband which is link to the hospital data base which is constantly transmitting information about the patient. Many medication carts are equipped with laptops and scanners which the nurses can use to scan the patient’s wrist band to bring up patient’s room and medication information. If there is not a match between the patient and the medication a warning box will pops up on the screen for further review. A total of 300 medication errors are reported and reviewed each month by the FDA and classified according to their cause. Base on significant findings, the FDA can change the labels, names, or packages of a drug . In addition, once a problem is discovered, the FDA educates the public on an ongoing basis to prevent repeat errors. Hospitals and other health care organizations working together can reduce the number medication errors greatly by using technology.
Pharmacy intervention the pilot program decreased the number order errors by 84%. A complete history of the patient medication was listed on the program and then discussed with the patient before any surgical procedures. The list of medication was then forwarded to the surgeon and he would make the decision on which medication to use base on their interactions and which ones were best for the patient.
Computerized Physician Order Entry (CPOE), has proven to be effective in reducing medication errors, because medication order are being entered directly into the computer by the physician himself, therefore, decreasing the number of medication errors by way of transcription. According to a survey by the Institute for Safe Medication Practices out the 1,500 hospitals surveyed in 2001 only 3 percent of hospitals were using CPOE, but they found CPOE to be helpful in decreasing errors because there were no misinterpretation of handwriting, decimal points, or abbreviations putting everything into the digital world. and the number hospital using the program has since increased..
A proposed revamping of safety reporting requirements aims to enhance the FDA's ability to monitor and improve the safe use of drugs and biologics. In 2003, the FDA published a proposed rule. The rule, if enacted, would improve the quality and consistency of safety reports, require the submission of all suspected serious reactions for blood and blood products, and require reports on important potential medication errors.