Inquiry into Evidence-Based Practice Paper II – Medication errors

Although overall patient safety in health care remains a top priority, medication errors remain a serious threat to effective clinical outcomes. Medication errors are defined as any preventable event (including inappropriate medication use and patient harm) that could occur at different stages of the medication process (namely, prescription, transcribing, dispensing, administration and monitoring). Adequate treatment is affected by these errors with adverse drug events (ADEs), increased hospitalizations, longer hospital stays, higher mortality, and greater healthcare costs: Inquiry into Evidence-Based Practice Paper II – Medication errors.

The Institute of Medicine (IOM) identifies six fundamental aims of health care: safety, timeliness, effectiveness, efficiency, equity, and patient-centered. While medication errors might not seem as serious as most critical failures in today’s healthcare organizations, that does not mean they do not have a tremendous impact on patient safety, effectiveness, and timeliness.

This problem presents itself as a problem that needs to be addressed with a structured, evidence-based approach, utilizing quality improvement tools with interdisciplinary collaboration. The purpose of this paper is to assess the effect of medication errors, substantiate with research, detail data acquisition, utilize quality initiatives, and formulate a structured intervention based on the Plan-Do-Study-Act (PDSA) model.

Identification and Discussion of the Problem

Among the preventable causes of patient harm in healthcare settings, medication errors are among the leading. According to Rodziewicz et al. (2024), approximately 1.5 million medication-related adverse events happen in the US every year and generate 3.5 billion excess costs in healthcare. Possible causes of these errors include distractions, poor communication, high workload, inadequate medication reconciliation or inefficiencies in their system.

The failure to follow the basic principles of administration of medication is one of the most common causes of medication errors. In order for nurses and other healthcare providers to perform when required, there is a strict set of guidelines for them to follow to make sure the correct medication is given to the right patient at the right dose by the right route at the right time (Rodziewicz et al., 2024). Medication administration errors compromise patient safety when they occur in deviation from these principles. Other healthcare provider communication breakdowns also contribute to errors, including the inability to read handwritten prescriptions, errors when taking verbal orders, and trouble understanding the content of electronic health records (EHRs).

Notably, the problem is compounded by interruptions and distraction during administration of the medication. As per Tsegaye et al. (2020), nurses preparing and administering medication are frequently interrupted, which results in loss of concentration and increased error rates. Also, look-alikes and sounds alike medication lead to confusion, particularly in highly stressed environments such as emergency departments or intensive care units. In view of these challenges, it is important to introduce systematic interventions intended to reduce medication errors and improve patient safety.

Evidence Supporting the Problem

The evidence of the impact of medication errors on patient safety is accumulating in a growing trend. Observational analyses in hospitals show that at least 25% of all medication errors happen when nurses administer the drugs, making them the ‘last line of defense’ against preventable ADEs (Tariq et al., 2024). Hospital risk management teams supply incident reports indicating medication errors in which dosages are missed, medications are not given at all, or are given to the wrong patient.

Additionally, patient complaints often focus on incidents where the patient was given the wrong medication or was harmed by an error during administration. Furthermore, the World Health Organization (WHO) also lists medication safety among the highest global patient safety priorities, pointing out that poor communication between healthcare professionals is mainly responsible for nearly 38% of medication-related errors. Realizing the pervasive and impactful ways these errors manifest, efforts to reduce them through data-driven quality improvement initiatives are imperative to the maintenance of patient well-being.

Besides, medication errors are directly linked to three of the six IOM aims for healthcare quality: safety, effectiveness, and timeliness. Preventable harm resulting from medication errors compromises safety and effectiveness diminished due to patients not receiving the correct treatment as intended. Also, timeliness is affected by errors since it requires some time to correct the wrong actions before patient care resumes as usual. Healthcare organizations that implement evidence-based interventions adhere to these principles of healthcare quality, and overall patient outcomes are increased.

Data Collection for Monitoring Progress

The data collection should target the medication administration’s structure, process, and outcome to minimize medication error parameters. Structural data includes information on existing medication administration protocols, staffing levels and use of technology. This process data consists of tracking medication administration workflow to discover error-prone steps and assess compliance with safety protocols. The outcome measures of surgical intervention include the rates of medication errors, reduction of patient harm, and overall medication safety improvement.

Tariq et al. (2024) indicate that hospitals typically collect data on medication errors, including incident reporting systems, counting on electronic health records, and direct nurse observations. The analysis of this data as a trend allows for patterns common to healthcare organizations to be identified, the effectiveness of interventions to be assessed, and refinements in medication safety strategy.

Quality Improvement Tools for Addressing Medication Errors

Moreover, several quality improvement tools are useful in identifying and dealing with medication errors. Control charts are frequently used to help track medication error rates over time so that healthcare teams may monitor trends and assess the success of interventions, according to Ciapponi et al. (2021). Fishbone diagrams, or Ishikawa, categorize causes of the contributing factors in the case of medication errors, such as human errors, environmental influences and process inefficiencies.

Failing mode and effects analysis (FMEA) is another major way of proactively finding out where failures can be made in a given event. As a result of FMEA, high-risk areas are systematically identified, and preventive measures are enforced to reduce the likelihood of medication errors. They are good healthcare quality improvement tools that may help healthcare professionals have a data-driven methodology to achieve continuous improvement in patient care.

Furthermore, integrated teamwork is essential for the successful implementation of medication safety initiatives. Nurses, as frontline providers, have the roles of medication administration and error prevention. Pharmacists address medication reconciliation, dosage verification, and drug interaction monitoring.

The leaders in the initiation of these initiatives are hospital administrators who provide policy and leadership support, as well as IT specialists who provide support for embedding electronic medication safety systems. A collaborative culture amongst these key stakeholders will equip healthcare organizations to perform every bit of what is possible to build a culture of medication safety and accountability.

Quality Improvement Plan Using the PDSA Cycle

The PDSA cycle-based structured quality improvement plan can be applied to reduce medication errors and improve patient safety.

Plan

The purpose of this intervention is to decrease 30 percent of medication errors in six months by integrating barcode medication administration (BCMA) technology and training programs in the staff. The implementation of the intervention will rely on the contribution of the interdisciplinary collaboration among nurses, pharmacists, IT specialists, and hospital administrators.

Do

One hospital unit will pilot BCMA as feasible and effective as part of a two-month pilot program. During this time, nurses and medical pharmacists will still have training in barcode scanning, error reporting, and best practices for medication administration (Manandi et al., 2023). Educational workshops will reinforce the principles of safe medication administration, and the use of strategies to minimize distractions will be employed.

Study

Pre-implementation and post-implementation medication error rates, nurse compliance with BCMA procedures, and patient safety outcomes will be collected. Trends will be analyzed through the use of control charts, and staff feedback will be collected to assess workflow efficiency and areas to improve.

Act

If the BCMA system proves to have a substantial reduction in medication errors, it will be expanded throughout the hospital. Staff feedback will be used to refine the training modules, and long-term monitoring systems will be put in place to maintain improvements in medication safety.

Conclusion

Improving patient safety in regard to medication errors is a challenging problem in healthcare and requires a structured and evidence-based approach. Healthcare teams can use quality improvement tools such as control charts, Ishikawa diagrams, and FMEA to identify and eliminate the root causes of errors. Using the PDSA model ensures continuous improvements in medication administration by providing a systematic framework to implement and evaluate interventions. Integrating data, driving decisions, and developing technology-driven solutions can allow healthcare organizations to deliver and care for patients safely, effectively, and in a timely manner.

References

Anjalee, J. A. L., Rutter, V., & Samaranayake, N. R. (2021). Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process – a study at a teaching hospital, Sri Lanka. BMC Public Health, 21(1). https://doi.org/10.1186/s12889-021-11369-5

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

Manandi, D., Tu, Q., Hafiz, N., Raeside, R., Redfern, J., & Hyun, K. (2023). The evaluation of the Plan-Do-Study-Act cycles for a healthcare quality improvement intervention in primary care. Australian Journal of Primary Health, 30(1). https://doi.org/10.1071/PY23123

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

Tariq, R., Scherbak, Y., Vashisht, R., & Sinha, A. (2024, February 12). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 13(13), 1621–1632. https://doi.org/10.2147/ijgm.s289452

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