Best Practices in Addressing Medication Errors in Healthcare

Healthcare Problem Overview

Summary of the Healthcare Problem

Medication errors remain a significant problem in healthcare delivery, provoking adverse patient consequences and additional treatment costs. Such mistakes can happen at any point in the medication cycle, during prescription, preparation, or even when dispensing the medications. The World Health Organization (WHO) describes 1.5 million adverse drug events that are considered preventable happening in the United States each year (Rodziewicz et al., 2024): Best Practices in Addressing Medication Errors in Healthcare.

These failures consist of wrong dosages, failure to prescribe medications, and adverse drug combinations, which normally result in adverse effects on patients, causing extended hospital stays and readmissions. Even with the adoption of technology like BMA, medication errors are still rampant in hospital settings.

Professional Relevance of Medication Errors

This topic is paramount for healthcare providers, including nurses, pharmacists, and physicians. Medication errors affect not only patient health but also the trust that patients place in healthcare providers. Healthcare professionals must reduce avoidable medication errors because these are some of the most fatal mistakes a professional can make. As a nurse, I have been a witness to medication errors, such as wrong medication given because of the passing of shift information that is inadequate or inaccurate. These have kept me ‘on my toes’ searching and ensuring that I adopt the best practices to avoid making errors.

Personal Experience with Medication Errors

In my practical experience, I have witnessed situations that involved medication errors due to a lack of communication, insufficient checks, or because of busy work. One instance entailed giving a particular drug at the wrong time because the response to the patient’s needs was not passed from the shift workers to the incoming ones. Even though the error mentioned above was detected at the first stage, the possibility of adverse consequences revealed the necessity of more severe safety measures and more comprehensive control. This shows how simple an error can be and how disastrous the effects can be, highlighting the need for a safety culture.

Relevant Peer-Reviewed Articles and Their Credibility

To explore best practices in addressing medication errors, a search was conducted to identify peer-reviewed journal articles published within the last 3–5 years. The databases used include PubMed, CINAHL, and Google Scholar. Subsequently, the search terms employed include “medication errors,” “patient safety,” “pharmacy practices,” and “preventing medication errors.”

The criteria for selecting articles included relevance to the topic, credibility (peer-reviewed), and a focus on evidence-based solutions. The articles chosen are current (published within the last 3-5 years) to ensure the information is up-to-date and reflects the most recent practices and research in medication safety. Notably, the search process aimed to identify strategies that could directly impact reducing medication errors in hospital settings, especially focusing on technological interventions, procedural improvements, and education-based solutions.

Annotated Bibliography

Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., Perdomo, H. A. G., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Elorrio, E. G. (2021).
Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2

This article provides a systematic review of the various studies aimed at reducing medication errors among adult hospital patients. These analyzed concepts are also related to several strategies, such as tool and technology, workflow, and education approaches. Medication errors in the hospital environment are a significant problem because they involve patient safety and overall healthcare outcomes. The review compiles the general findings of several works to draw an overall conclusion on the role of these interventional measures in minimizing errors.

Strategies discussed are point-for-point communication technology, namely CPOE systems, barcode medication, and a leading role for pharmacies. CPOE systems reduce medication prescribing errors due to poor writing or wrong interpretation by other physicians. Barcode medication administration is an extra check and balance that helps to check and ensure medications before administering them. Another intervention that helps reduce the risk of medication mishaps is medication review by the pharmacist; this helps to purge the system of wrong prescriptions to fit the patient’s condition.

Ciapponi et al.’s (2021) article was included because it covers the content on medication errors in hospitals. As the study also shows, increased technology application must be combined with human supervision to enhance medication safety. These interventions are critical to establishing the multiple barriers to error and improvement in patient care.

Koyama, A. K., Maddox, C.-S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020).
Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

Koyama et al. (2020) explore whether double-checking procedures help decrease medication administration errors in healthcare facilities. Drawing from other papers, their article reviews the effects of double-checking through healthcare practitioners or checklists. It aggregates information from multiple environments, such as a hospital and outpatient clinic, to determine the effects of decreasing medication mistakes from this intervention.

This article is significant because it studies the great ‘double check’, a method widely used in the identification of avoidable mistakes in clinical medicine involving medication errors. The study gives important information concerning the extent to which this practice reduces medication errors. The review also established that double-checking is effective in decreasing errors, particularly where the possibility is higher, such as in oncology. However, the article notes that double-checking alone is not enough; a safety culture and other preventive measures are needed to eradicate medication errors completely.

Sandra, P.-C., Alba, C.-P., & Cristina, M.-M. (2022).Use of simulation to improve nursing students’ medication administration competence: A mixed-method study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-00897-z

Sandra et al. (2022) examine the simulation-based education type to increase the level of competence of nursing students in medication administration. The purpose of the study was to explore the extent to which simulation training enhances students’ knowledge of safe medication administration. The survey incorporates quantitative analyses of the knowledge students demonstrated with qualitative opinions about the program from participants.

This article is relevant to the training of the next generation of healthcare professionals, specifically in nursing and medicinal safety. It is important for students and future nurses to learn about safe medication administration to prevent recurrent medication errors in healthcare systems. Notably, the study found that medication administration skills and confidence are enhanced through simulation-based training. Also, the students confirmed that the utilization of simulation provided them with confidence in clinical settings, cutting down any medication errors in advance practice.

Stolldorf, D. P., Ridner, S. H., Vogus, T. J., Roumie, C. L., Schnipper, J. L., Dietrich, M. S., Schlundt, D. G., & Kripalani, S. (2021). Implementation strategies in the context of medication reconciliation: A qualitative study. Implementation Science Communications, 2(1). https://doi.org/10.1186/s43058-021-00162-5

The article examines the best practices for medication reconciliation in healthcare, and the authors explain the kind of problem the healthcare workforce has regarding verifying and correcting patients’ medication history. This article discusses the various approaches for reconciliation, especially for communication, formalism, and teams, with the view of improving the accuracy and safety of the processes in place.

This study is important because medication reconciliation is one of the effective safety measures for avoiding medication discrepancies, especially in cases of transfer from one care setting to another. The article also highlights that challenges that affect the effective implementation of applications include inadequate time and lack of comparability of health systems. The research finds that there is no straightforward way to achieve effective reconciliation and that it can only be achieved when training, communication, and use of technology are done well. The aim is to be guided by the best strategies on how medicine reconciliation should work since simple barriers like inadequate time and unclear procedures must be overcome to make this important process effective in minimizing medication mistakes.

Summary of Key Learnings

Developing the annotated bibliography provided a deeper understanding of medication errors and how to mitigate them. I learned that these errors can occur at any stage of the medication process, including prescribing, dispensing, and administration. While technological tools like barcode medication administration and CPOE are effective in reducing errors, human oversight remains essential. Medication reconciliation, especially during patient transitions, is also crucial in preventing errors that often occur when patients move between care settings.

Furthermore, while reviewing the sources, I learned that the approach toward minimizing the frequency of medication errors is complex to some extent. The research focused on interprofessional relationships, the works of the nurses in particular, and education. Interestingly, medication reconciliation has been found to work hand in hand with technology, standard operating procedures, and adequate training.

In sum, technology (like CPOE and barcode scanning) reduces errors, medication reconciliation during care transitions is vital, nurse-led interventions reduce errors in high-risk areas, and ongoing education and training are necessary for competence. Notably, the sources contributed key insights into how integrating these strategies can enhance patient safety and minimize medication-related harm.

Conclusion

Medication errors continue to be a significant concern in healthcare, but evidence-based strategies exist to mitigate these risks. Technological interventions, medication reconciliation, nurse-led initiatives, and education programs are all proven to reduce medication errors. By integrating these approaches into clinical practice, healthcare providers can improve patient safety, enhance the quality of care, and reduce the healthcare costs associated with adverse drug events. A comprehensive approach combining these elements will be most effective in addressing medication errors and ensuring safe, efficient patient care.

References

Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., Perdomo, H. A. G., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Elorrio, E. G. (2021). Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2

Koyama, A. K., Maddox, C.-S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of Double Checking to Reduce Medication Administration errors: a Systematic Review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024, February 12). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Sandra, P.-C., Alba, C.-P., & Cristina, M.-M. (2022). Use of simulation to improve nursing students’ medication administration competence: A mixed-method study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-00897-z

Stolldorf, D. P., Ridner, S. H., Vogus, T. J., Roumie, C. L., Schnipper, J. L., Dietrich, M. S., Schlundt, D. G., & Kripalani, S. (2021). Implementation strategies in the context of medication reconciliation: A qualitative study. Implementation Science Communications, 2(1). https://doi.org/10.1186/s43058-021-00162-5

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