Medical Mistakes: Literature Review

Topic: Nursing
Words: 1344 Pages: 5


Pharmaceutical compositions are the cornerstone of scientific medicine, as a wide range of diseases became curable due to the discovery of helpful drugs. However, a certain substance can be a remedy solely on the condition that healthcare professionals abide by the rules of safe admission. Not adhering to the standards bears substantial risks for the patient, up to a lethal outcome. Specifically, medication errors cause 98,000 deaths yearly, exceeding the fatal consequences of AIDS, vehicle accidents, or work injuries (Saljoughian, 2020, p. 10). The statistics of that kind make it critical to identify the possible ways of minimizing hospital medical mistakes. Therefore, the paper’s purpose lies in a critical analysis of the topic-related data and the subsequent development of the most appropriate solutions.

Methods of Searching

A literature review was conducted using both electronic and manual resources. The initial step involved collecting information on medication mistakes from peer-reviewed articles whose authors had investigated the topic between 2016 and 2021. The tool for conducting the research was Google Search which enabled scanning multiple writings in a short time frame, hence simplifying picking the most relevant among those. The data underwent both quantitative and qualitative analysis, which allowed for identifying the seriousness of the problem and its most probable causes, respectively. The final stage presupposed suggesting reasonable solutions, the implementation of which would reduce the risk of unwanted consequences of drug treatment.

Project Proposal Topic

The project proposal targets to find the solutions that would allow for reducing the frequency of medical errors. The initial step lies in classifying those which task may be challenging due to the dramatically limited room for measurement (Rodziewicz et al., 2021). Notably, there are several possible criteria for describing and categorizing improper actions

of healthcare professionals, each of which is qualitative rather than quantitative. Then, it is essential to identify the most common reasons why medical practitioners may perform inadequately, relying on the outcomes of the relevant surveys. Finally, it is necessary to search for the most effective ways to minimize the influence of the factors that cause errors, hence the amount of the latter.

Analysis of the Sources

Classifying Medical Errors

Improper results of medication admission derive from various mistakes that nurses make in the process. Thus, Rodziewicz et al. (2021) describe two major categories of errors: of omission and of commission. Omission means not taking necessary actions, for instance, not replacing the used needle prior to injection. The commission happens when the actions are wrong, including administering a certain substance to a patient who is known to be allergic to it.

In terms of severity, medication mistakes are possible to classify by such criteria as actual harm and potential harm. While the former is observable in real-time and, consequently, assessable, the latter is based on assumptions and probabilities, hence not necessarily precise. Considering this, the existence of potential harm is the key determinant of the error’s seriousness. Simply stated, any mistake that bears a threat to the patient, notwithstanding its type and degree, is “major”, “problematic”, “high risk”, or “clinically significant” (Gates et al., 2019, p. 933). These interchangeable terms mark the higher of two severity levels, while a mistake that bears little to no potential harm is “minor” or “insignificant” (Gates et al., 2019, p. 933). Although such a classification may seem dramatically general, it is sufficient to determine further actions in each case.

Research on the Causes of Medical Errors

Incorrect steps are inevitable in any activities, including healthcare, simply because none of the human being is able to perform perfectly on a constant basis. Furthermore, Bari et al. (2016) insist that medical errors are, in fact, more common than the population may believe them to be due to frequent underreporting. According to the experts, insufficient recognition of improper actions of personnel complicates the identification of their causes. One of the most effective methods apparently is an anonymous survey, as it requires neither specifying the name and location of the facility nor any personal data of the respondent. Having conducted such research, the investigators found that the majority of medical errors derived from a lack of experience or knowledge (52% and 40%, respectively) and overworking-related exhaustion (66%) (Bari et al., 2016, p. 525). Simply stated, many practitioners make mistakes since they are not sufficiently competent or attentive to realize what they are doing.

Meanwhile, it is critical for a health professional to be aware and concentrated, as the occasions that can have unwanted consequences are numerous but often seemingly minor, hence easy to miss. Among those are, for instance, handwritten orders that a nurse, especially a newcomer, is not necessarily able to decipher correctly (Saljoughian, 2020). Another common mistake in both making and interpreting prescriptions is the incorrect use of zeroes and decimal points in dosages, which can lead to a 10-fold error in drug administration. Such factors as poor lighting and similar-sounding or similar-looking medications also contribute to the probability of incorrect steps.

Summary on Preventative Measures

Although it is impossible to eliminate mistakes, they can be minimized. Thus, Saljoughian (2020) describes the key principle of appropriate drug administration, which he refers as the five rights: “the right patient, drug, dose, time, and route” (p. 10). These are the key points to double-check before giving a substance to a person. In fact, thorough control is one of the ways to avoid mistakes the researcher offers. According to him, more than one professional should review new orders to confirm that all of the records are correct. In addition, he highlights the essentiality of educating nurses, in particular, on the warnings that drug labels bear, lists of the medications that look or sound alike, and others. Considering the above statement that the lack of competence is among the most common sources of medical errors, such an approach is doubtlessly relevant.

It is worth noting that the healthcare industry is developing, which makes it crucial even for highly qualified practitioners to improve their knowledge. For instance, Salar et al. (2020) mention that new drugs appear on a regular basis, while nurses, as well as doctors, are not necessarily aware of their prescription methods, compatibility, or contraindications. This is another factor in determining the importance of never-ending education.

All of the above allows assuming that medical errors do not occur spontaneously and independently but emerge systematically from the poor organization of a particular facility. Specifically, Rodziewicz et al. (2021) proclaim that insufficient interaction among staff members, a common problem, prevents those from exchanging information and expanding their knowledge. Improper staffing, in other words, hiring undereducated or careless individuals, is on the list of limitations as well. This drives the conclusion that medical institutions should reconsider their corporate policies, notably, develop more effective employment strategies and provide closer personnel communication for their patient’s safety.

Sleep deprivation and fatigue that accompany overworking and can lead to fatal outcomes are another consequence of ineffective interaction, in this case, between practitioners and administration. Bari et al. (2016) insist that therapy is teamwork, which presupposes permanent awareness of other participants’ difficulties. Since the well-being of medical professionals is one of the key factors in determining their productivity, the situation where nobody knows about a nurse’s inability to work appropriately because of sleepiness is unacceptable.


Medication errors occur inevitably simply due to the imperfection of human beings, but their amount is to be minimal. This can be reached by reducing or eliminating the factors that increase the probability of an incorrect step. Among them is, for instance, the lack of both theoretical knowledge and practical experience in medical practitioners, which is derivable from poor staffing along with insufficient in-house training. Working long hours without breaks is another cause of errors, as it results in sleepiness and the inability to concentrate. Inappropriate work schedules, in turn, result from little to no communication between personnel and administrations of medical facilities (Bari et al., 2016). Considering all of the above, it is possible to state that improving the effectiveness of educating staff members and interaction among them is critical for minimizing the rate of medical errors.


Bari, A., Rehan, A. Kh., & Rathore, A. W. (2016). Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan Journal of Medical Sciences Online, 36(2), 523-528. Web.

Gates, P. J., Baysari, M. T., Mumford, V., Raban, M. Z., & Westbrook, J. I. (2019). Standardizing the classification of harm associated with medication errors: The harm associated with medication error classification (HAMEC). Drug Safety, 42, 931-939. Web.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. StatPearls Publishing. Web.

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. Web.

Saljoughian, M. (2020). Avoiding medication errors. US Pharmacist, 45(6), 10-11. Web.

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