Medication errors are a major problem in the healthcare system and one of the most prevalent medical errors that endanger patient safety and can result in serious harm or even death. This assessment will review and discuss the problem of medical staff making mistakes with their patients’ medication, which can lead to serious harm or even death. Any time a health care provider, patient, or consumer makes a mistake with medicine while it is in their possession, it is considered a medication error. Maintaining a secure healthcare system requires constant vigilance to prevent medication errors at every possible point in the process, from initial prescription through final disposal (Dirik et al., 2018). While many hospitals and clinics have rules to prevent drug mistakes, there may be room for improvement.
Elements of the Problem/Issue
Medication errors continue to be one of the most common causes that put patients at risk and place a significant financial burden on the healthcare system. During the phase in which nurses administer care, patients are injured by errors around one-third of the time (Piroozi et al., 2019). The severity of the patient’s condition and the amount of work that the nurse has to do, distractions and interruptions that occur while the medication is being administered, and a failure on the part of the nurse to adhere to policies or guidelines are all factors that contribute to medication errors.
The severity of the patients and the amount of work that nurses have to do contribute to fatigue. This makes nurses more likely to have trouble concentrating on their duties and potentially make more errors (Dirik et al., 2018). Patients with a high acuity level may have medical issues that are difficult to treat and frequently have considerable and unpredictable needs. In reality, this means that stable patients whose results are more predictable receive nursing care that is either less frequent or less intensive. For instance, a nurse’s safety is put at risk when they are assigned high-acuity patients because of the increased frequency with which she must administer medications to those patients. As a result, this has implications for nurses’ workload, measured by the number of patients per nurse at a hospital.
Distractions and interruptions during medicine administration are common causes of delays and errors (Gates et al., 2019). Patient call bells, fall alarms, and the presence or conversation of other persons in the medicine preparation room are all potential interruptions or distractions. The “rights of drug administration” is a double-checking technique used by nurses that, when done correctly, is a reliable form of verification. Medication errors can be reduced, and patients can be protected by limiting interruptions and other sources of disruption.
One of the most common individual contributors that might lead to medication errors is a failure to adhere to established protocols or recommendations. Most explanations for departing from standard procedure cited the need to conserve time (Dirik et al., 2018). Neglecting to check a patient’s identifying band in contrast to the patient’s medication sheet to ensure that the information is right is an illustration of not adhering to policies or procedures, as this is an example. Although time constraints and patient convenience play a part in the work of medicine administration, nurses have a responsibility to ensure that they are following the procedures designed to keep patients safe.
In my role as a staff nurse on a progressive care unit, it is essential for me to be mindful of medication errors, as these can impact patient safety. Due to the severity of my patients’ conditions, interruptions throughout my shift, and the amount of work I have to accomplish, I occasionally find it challenging to administer drugs at the appropriate times. When you have five patients with a high understanding and increasing medical demands, giving medications at the appropriate times might be challenging. When it comes to administering medications on my unit, adequate staffing ratios provide a challenge, which in turn results in errors in the administration of medications (Piroozi et al., 2019). Some medication errors are reported to the physician and the nursing manager, while others are recorded electronically on the EMAR (Electronic Medication Administration Record).
Context for Medication Error Issues
Medication errors can be prevented in the first place if nurses giving out pills take the time to ask questions about what they are giving the patient. It is common practice to examine pharmaceutical errors without considering the cognitive load that comes with doing so in complicated systems. Studies have shown that shifts of ten hours or more significantly increase the risk of burnout among nurses, and the risk of errors increases three-fold when staff members work for that time (Dirik et al., 2018). The nursing staff on a unit is under increased personal stress and pressure due to the increased number of patients they are responsible for. Because of the severity of the patients and the volume of work, pharmaceutical errors are more likely to occur, putting patients at risk. Understaffing, failing to consider patients’ medical conditions before admitting them, and prioritizing the facility’s bottom line over patient safety are all systemic failures to support nurses adequately. When nursing personnel is stretched thin, medicine administration slows, and vital patients are put in danger; because of this, everyone loses.
Populations Affected by Medication Error Issues
Medication errors can occur in patients who are in intensive care, patients who are undergoing surgery, patients who are being observed, inpatient patients, surgical patients, intensive care patients, monitored patients, and emergency patients are all at risk. Patients with conditions that last a long time are likely to know much about their typical medication. As a result, patients are often the final line of defense against errors related to their medication. According to a study conducted in Switzerland, the vast majority of oncology patients felt confident in their ability to monitor for errors and alert professionals (Piroozi et al., 2019).
Patients’ active participation in their medication management and corrections to nurse-to-patient ratios are two components of a culture of safety that can reduce medication errors in the hospital context. Medication safety checks that include patient participation could be helpful and should be considered part of the norm in ‘patient-centric care.’ Involving the patient in the therapeutic medicine administration process may lead to time savings and enhanced discharge preparation. By encouraging patients to take an active role in their drug management, we can help them achieve better outcomes (Gates et al., 2019). However, this is only possible if we provide them with a setting in which they feel safe and confident. Even though not all patients have the cognitive capacity to be involved in their medicine administration, this issue can be overcome with careful monitoring and open lines of communication between interdisciplinary team members.
Safeguarding patients requires nurses’ presence at the bedside. They are always there by the patient’s side and keep doctors, pharmacists, and loved ones apprised of their current health status. The nurses’ ability to offer safe care is diminished when they are assigned more and more patients. The ratio of nurses to patients is one-factor connecting nursing workload to patient protection. Studies have linked a greater number of patients per nurse to an elevated risk of burnout, further supporting the link between clinician fatigue and patient safety hazards. The complexity of their work and the urgency of their patients’ circumstances increase the risk of mistakes (Dirik et al., 2018). Management and nursing staff must work closely together to navigate the complex process of determining appropriate nurse staffing, which varies regularly. Improved coordination and communication between managers and frontline nurses is one potential solution for this strategy. Staff nurses may have a greater understanding of the types of patients admitted to the unit than managers and supervisors, and so they should be more often involved in making staffing decisions.
Accurate drug administration is a top priority for hospital patient safety; thus, nurses, patients, and managers must work together to find solutions. For instance, knowing why a patient’s medication was late and the causes of the delay can help avoid the problem in the future (Piroozi et al., 2019). There may not have been enough nurses on duty, or perhaps one of them got sidetracked and forgot, but involving the patient in the solution would have been a good idea.
Medical care providers need to comprehend the importance of doing no harm to their patients and acting in their best interests. Consequently, they should identify and report medication errors as early as possible so that appropriate action can be taken to mitigate the potential risk. Patients should be informed of drug mistakes to take an active role in determining their next course of therapy since it is their right to do so (Piroozi et al., 2019). A patient’s right to participate in decisions about their drug administration is consistent with the ethical principle of autonomy. Consequently, people have a voice in their healthcare decisions.
Implementation of the solution
Medication errors can be avoided with proper training and knowledge. Patient involvement and education are maintained throughout the medication administration procedure. Patient safety and the mitigation of pharmaceutical errors can be improved by adopting the “patient-centered care” approach. The patient’s input serves as a “last check” in the five rights of drug delivery that benefit both the patient and the nurse. It was established that one of the roles of the nurse was to educate patients on their medication charts, including the pharmacological properties of medications, the need for a medication review, and any changes in the patient’s condition that might necessitate a change in the patient’s dosage or frequency of administration (Gates et al., 2019). Policies like “right patient, right medication, right dose, right route, and right time” are in place to minimize the likelihood of such incidents occurring. These mistakes can be avoided with proper patient identification using both identifiers and by discussing the patient’s prescription schedule and list with the patient.
Hospitals and other healthcare facilities should provide a safe environment for their patients and staff. Accepting that mistakes are inevitable is the first step toward development. Using this knowledge, the administration can conduct more frequent safety checks and reduce the likelihood of such incidents. If you’re hiring new staff, look for those who are not afraid to admit when they’ve made a mistake and are willing to accept responsibility for fixing the problem. Improved care results from a collaborative effort; eliminating pharmaceutical errors requires giving the staff the tools and training they need to do their jobs well.
Dirik, H., Samur, M., Seren Intepeler, S., & Hewison, A. (2018). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5-6), 931–938.
Gates, P. J., Baysari, M. T., Gazarian, M., Raban, M. Z., Meyerson, S., & Westbrook, J. I. (2019). Prevalence of medication errors among paediatric inpatients: Systematic review and meta-analysis. Drug Safety, 42(11), 1329–1342.
Piroozi, B., Mohamadi-Bolbanabad, A., Safari, H., Amerzadeh, M., Moradi, G., Usefi, D., Azadnia, A., & Gray, S. (2019). Frequency and potential causes of medication errors from nurses’ viewpoint in hospitals affiliated to a medical sciences university in Iran. International Journal of Human Rights in Healthcare, 12(4), 267–275.