Running head: MEDICATION ERROR 1
Medication Error
Michael S. Mason
NURS 501: Health Policy and Ethics
MEDICATION ERROR 2
Introduction
There are many preventive measures in the healthcare industry in place to prevent
medication errors. Medication errors can be defined as any mistake in prescribing, dispensing, or
administering medication to a patient. These errors have the potential to cause harm to the patient
including fatal results. The prevention of medication errors should be the responsibility of all
healthcare professionals and it should be within the policies of all healthcare facilities. I chose to
write about medication errors because my staff recently experienced an error that was identified
by the pharmacy. The patient’s prescription had the wrong information and the pharmacy did not
dispense the medication. Luckily, there are many checks and balances involved in medication
prescription but I feel that the most important prevention starts with information verification.
The Event
I work for a pain management facility. Our patients are referred to our facility from their
primary care providers to primarily treat the patient’s pain as well as the source of the pain. The
majority of our patients are taking many medications including narcotics that should be verified
and regulated. This particular incident occurred in one of our newer facilities. The staff had been
hired many months earlier and had worked in one of our established facilities before transferring
to the new facility. As our patient referrals increased for the new facility, the new clinic became
more established. Even though the staff had been hired months before and had learned our
business practices, they were still establishing themselves in the new clinic. Our provider was a
midlevel provider who was also recently hired. She had many years of experience as a nurse
practitioner but mostly in family practice. She was also establishing herself in the new clinic
along with the new staff. Normally, the prescriptions are electronically sent to the pharmacy
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identified by the patient. Our electronic health record is set up to send these prescriptions
electronically using a numbered token specifically generated for each prescription. We use paper
prescriptions as a backup and also until each provider is credentialed and verified to use the
token system. Our new provider was in the verification process for the token system, so the staff
used paper prescriptions. This process worked well until we started to become busier with new
patients every day. At the end of each patient appointment, our medical assistants would type out
each paper prescription and print it out to be signed by the provider. It would then be given to the
patient to be taken to the pharmacy of their choice to be dispensed. At the time, the first check in
the prescription process would be the information verification by the medical assistants, the
second check would be the provider before the signature, the third check would be the patient,
and the final check is the pharmacy before dispensing the medication. On one of our busier days,
a medical assistant printed out several prescriptions for a patient. They were presented to the
provider for signature. The provider quickly signed them and moved on to the next patient. The
medical assistant then gave the prescriptions to the patient and the patient immediately left the
clinic for the pharmacy. The pharmacist did not dispense the medications because the
prescriptions were in someone else’s name. The pharmacy called the clinic to present the
incident.
Lessons Learned
The patient came back to the clinic and was given the right prescriptions that were
verified and had the right demographic information. The staff wrote this mistake off as a minor
mistake that was identified and corrected but as a clinic manager, I identify this mistake as a
major problem. This error had the potential to cause major harm to the patient. Luckily, the
wrong information in this incident was the patient’s name but what if the medication was typed
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differently or the dosage. The Health Insurance Portability and Accountability Act was also a
factor in this incident. Someone else’s name was on the prescription. This could have been a
major problem if any other identifying demographic information had been on the written
prescription. I saw this as a breakdown in the checks and balances system in our clinic. I needed
to make a change in the process to avoid future occurrences. According to an article titled,
Medical professionalism and the future of public trust in physicians, medication errors account
for the rising cases of patients’ experiencing the adverse reactions of prescribed drugs (Levey,
2015). We were establishing ourselves as a new clinic in the area and we were in the process of
gaining the trust of the referring clinics as well as the local pharmacies. More importantly, we are
charged with the safety of our patients. I established a new protocol for written prescriptions. The
new process starts with reviewing the treatment plan of the provider by the medical assistant. All
medications would be verified along with the correct demographic information. The lead medical
assistant will verify prescriptions before they are presented to the provider. The provider is also
charged with verifying the information before signing the prescriptions. Finally, the prescriptions
are explained to the patient before they leave the clinic. According to Michael R. Cohen, “While
e-prescriptions are recommended because they reduce the need for error-prone transcription of
handwritten prescriptions or telephone orders, the prescriber should always instruct patients or
caregivers as well and provide them with a copy of the prescription (clearly marked as a copy) or
an office summary listing the medication and directions for use. This way, the patients can verify
the prescription by matching the hard copy to what they receive from the pharmacy” (Cohen,
2018). The patient can and should be involved in the process to reduce these errors. This new
process places preventive measures in the avoidance of errors but also educates the patient on
their medication and allows them the time to ask any questions about their medications. .
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Conclusion
The prevention of medication errors have been one of the focuses in nursing protocol for
many years. The five rights: right patient, right drug, right dose, right route, and right time have
been established and taught to every level of medical professional. My staff forgot to use these
protocols because they felt like they were too busy. They needed to be reminded that every
patient deserves individual attention and medical professionalism. I used this incident as a
teaching point for the staff and I tried to keep it positive. It is impractical for me to believe that
we can completely eliminate errors but I think it is important to identify any errors in the future
so that we can identify the cause of the errors. Implementing protocols to establish prevention is
the key to promoting patient safety.
