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Preventing Medication Error in Nursing Tredia Pereira

College of Nursing, Resurrection University

NUR 4642- Professional Role Transition

Professor Brandon Hauer

March 14, 2021

Preventing Medication Error in Nursing

A medication error is defined 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,” according to the National Coordinating Council for Medication Error Reporting and Prevention (Center for Drug Evaluation and Research, 2019). Unfortunately, medication errors happen frequently, and their type and frequency vary in hospitals and nursing homes, and it can lead to serious injuries or even deaths. It can occur from the prescribing the medication stage to the administering stage, and although most of it does not end up in patient’s death, it is a common problem in the healthcare world. “The adverse events and errors committed by health care professionals pose a threat to patient safety and may have minor or severe consequences, even resulting in injury, disability, or death. Because of its importance, patient safety is now a health policy priority worldwide” (Asensi-Vicente et al., 2018).

On the telemetry floor, medication error is pertinent because some of the patients that get admitted to the floor come with a wide range of diseases that could require multiple medications being prescribed. Their medication list has sometimes six to ten medications and nurses on the floor have up to five patients per shift. It is very easy to make a mistake by selecting the wrong patient and withdrawing the wrong medication and that almost happened to one of the nurses I was shadowing.

One of the nurses on the unit supported the topic and expressed how relevant the topic is to the unit because it is very easy to make a mistake if you are overwhelmed by your patients’ needs especially since they all have different needs, and some are more difficult than others.

Preventing medication errors on the floor not only will help keep the patients safe, but it will also prevent the nurses from losing their license because it is possible to happen if a serious injury occurs after the error. Taking extra precautions on the unit can also increase a sense of security among the patients and help decrease their fear of not receiving the appropriate care. Adding preventive measures can also decrease patients’ anxiety and uncertainty due to them feeling more secure and protected by specific and intentional safety measures put into place to better the care they receive.

Literature Review of the problem

In an article by Almalki et al, the authors focused their research on the rate of medication errors in Saudi Arabia by doing meta-analysis in the hospital settings. They stated that medication errors “remain the eighth leading cause of amenable and preventable death in the United States of America (USA), causing about 225,000 deaths each year. According to various studies on drug related hospital admissions, 5% to 6% of all hospitalizations are due to medication-related problems” (Almalki et al., 2021). They also explained reasons or events that can lead to medication errors and some of them are “patients commonly receive new drugs or have alternate drugs due to drug formularies limitations which could limit to certain medications during the hospitalization. In addition, the lack of communication, understanding, and collaboration among providers is a significant factor in preventable MEs after hospital” (Almalki et al., 2021). To conduct the study, they performed four group analyses according to the type of errors and most studies were analyzed in more than one group. In this meta-analysis, in this meta-analysis, the authors found a significant variation in the reported rates of medication errors in different hospitals in Saudi Arabia. The authors were able to use 16 studies in Saudi Arabia to evaluate the rate of medication errors in hospitals during the stages of prescribing, dispensing, and administration. The integrated medication error rate in Saudi Arabia hospitals was estimated to be 44.4% which is very high and shows how often it does happen. Furthermore, the study highlighted that the most frequently reported category of medication errors according to medication-use process stages is in the medication-prescribing stage which is very concerning and puts patients in danger.

Waaseth et al composed a study on medication errors and patients’ study in a Norwegian hospital and discovered that “medication errors are associated with prolonged hospitalizations at higher health costs and represent increased burdens for patients and public healthcare services. The cost of unwanted medication incidents in the US has been estimated to $3.5 billion annually and Norwegian health institutions are obliged to report unwanted incidents where such incident has resulted, or might have resulted, in considerable personal injury” (Waaseth et al, 2019). Medication error is punitive and because of that, a lot of healthcare workers do not report it when it happens in fear of losing their job which result in a lot of medication error not being reported. The authors discovered that “nurses, more frequently than doctors, reported medication errors and discussed reported errors at staff meetings. Doctors preferred to solve the problem directly, for example writing a new medication order, rather than writing a report when a medication error had been identified” (Waaseth et al, 2019). The discussed that the aim of medication error reporting is to learn from our mistakes, and to continuously improve treatment and ultimately treatment outcome. Reporting medication errors improves the safety of future patients and helps prevent serious injuries that could happen from it.

References

Center for Drug Evaluation and Research. Working to reduce medication errors. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors.

Asensi-Vicente, J., Jiménez-Ruiz, I., & Vizcaya-Moreno, M. F. (2018). Medication errors involving nursing students. Nurse Educator, 43(5). https://doi.org/10.1097/nne.0000000000000481

Almalki, Z. S., Alqahtani, N., Salway, N. T., Alharbi, M. M., Alqahtani, A., Alotaibi, N., … Alshammari, T. (2021). Evaluation of medication error rates in Saudi Arabia. Medicine, 100(9). https://doi.org/10.1097/md.0000000000024956

Waaseth, M., Ademi, A., Fredheim, M., Antonsen, M. A., Brox, N., & Lehnbom, E. C. (2019). Medication Errors and Safety Culture in a Norwegian Hospital. Studies in health technology and informatics, 265, 107–112. https://doi.org/10.3233/SHTI190147