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Medication Errors

Medication Errors

Medication Errors

Committee: Medication Management

Element of Performance: MM.06.01.01- MM-19

Standard: The hospital safely administers medication (JCR, 2012).

A hospital should put into writing the personnel that is authorized, with or without supervision, to administer medication as per the laws and regulations. Although only authorized persons are allowed to administer medication, patient self-mediation is also permitted where indicated. The person authorized to administer medication must verify that the drug is the same as shown on the product label and the medication order (JCR, 2012). This element ensures that patients are given the proper medication to treat the coinciding illness and that medical errors are avoided. Additionally, the part provides that the right quantities of drugs are given even as the authorized personnel can determine the amounts without supervision to avoid underdosing or overdosing.

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D with a circle: only persons who are authorized can administer medications. Authorized personnel should be defined in writing within the hospital policies to avoid any future misunderstandings.

Three with a triangle: medication administered should be counterchecked to confirm that it is the same as indicated on the product label and in the medication order.

Medication errors occur in healthcare, including wrong time intervals, dosage forms, and routes (Keers et al., 2013). Today it is common for medication errors to be reported in healthcare facilities and is responsible for high costs, mortality, and morbidity. According to the World Health Organization (2017), poor labeling has been cited as a major cause of medication errors. Mohan et al. (2013) state that the specific format and content of prescription drug labels allow for communication with the patients and comprehension of the same.

In this case study, the variability in drug labeling and the use of terminologies hurts the medication instructions understood by patients. Additionally, illegible handwriting by the prescribing physician or the pharmacist that dispenses the medication can cause significant errors and adverse effects (Aronson, 2009). The pharmacist will likely dispense the wrong dosage when the physician prescribes illegible handwriting. When the clinical personnel authorized to administer the drug reads the pharmacist’s instructions, not knowing that an error has already occurred, they will help the medication, which can result in mortality, and irreversible effects, among others (Jeetu & Girish, 2010). Further, where patients are allowed to self-administer drugs, but the same has been wrongly labeled, they will suffer the consequences of the wrong dosage.

Patients that are chronically sick or who are very elderly are at the highest risk of experiencing errors in medications as they are the categories of persons that often have numerous prescription drugs per annum (Lavan et al., 2016; Schoen et al., 2011). For the elderly, problems with sight can also cause them to misread the label and either underdose or overdose on a medication (Barber et al., 2009). Further, drugs with similar names can easily be mistaken during administration or when the pharmacist dispenses them (Ostini et al., 2012). Errors in pronunciation can be due to the clinician’s phonetic challenge, which can cause the wrong medication amount and form to be entered as the prescribed dose.

Proverbs 16:20 admonishes us that whoever gives heed to instruction prospers and is blessed is the one who trusts in the Lord. Ecclesiastes 4:9, 12 also states that ‘Two are better than one… A cord of three strands is not quickly broken’ When medical personnel is meticulous in ensuring that the labeling is done correctly and that personnel is not afraid to ask for verification from the prescribing physician, communication will be open, and errors will be fewer. When a pharmacist or a nurse cannot understand the instructions on a label, they should ask the prescribing clinician to clarify. Doing so will save the patient and the hospital unnecessary costs from medication errors. All personnel should work in unison to care for the patient to ensure the best possible outcomes.

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Aronson, J. K. (2009). Medication errors: what they are, how they happen, and how to avoid them. QJM: An International Journal of Medicine102(8), 513-521.

Barber, N. D., Alldred, D. P., Raynor, D. K., Dickinson, R., Garfield, S., Jesson, B., … & Carpenter, J. (2009). Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. BMJ Quality & Safety18(5), 341-346.

JCR (2012). Hospital accreditation standards 2012. Joint Commission Resources, 2011-Hospitals

Jeetu, G., & Girish, T. (2010). Prescription drug labeling medication errors: a big deal for pharmacists. Journal of Young Pharmacists2(1), 107-111.

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Annals of Pharmacotherapy47(2), 237-256.

Lavan, A. H., Gallagher, P. F., & O’Mahony, D. (2016). Methods to reduce prescribing errors in elderly patients with multimorbidity. Clinical interventions in aging11, 857.

Mohan, A., Riley, M. B., Boyington, D., Johnston, P., Trochez, K., Jennings, C., … & Kripalani, S. (2013). Development of a patient-centered bilingual prescription drug label. Journal of health communication18(sup1), 49-61.

Ostini, R., Roughead, E. E., Kirkpatrick, C. M., Monteith, G. R., & Tett, S. E. (2012). Quality Use of Medicines–medication safety issues in naming; look‐alike, sound‐alike medicine names. International Journal of Pharmacy Practice20(6), 349-357.

Schoen, C., Osborn, R., Squires, D., Doty, M., Pierson, R., & Applebaum, S. (2011). A new 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Affairs30(12), 2437-2448.

World Health Organization. (2017). Medication without harm(No. WHO/HIS/SDS/2017.6). World Health Organization.


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Medication Errors

Please see the attached copy of the reading assignment, and there is another reading assignment on google books for the “2012 Hospital Accreditation Standards”.

Medication Errors

Medication Errors

To find the reading assignment, please do a word search on Google for Google books. Then, on Google Books, do a word search for 2012 Hospital Accreditation Standards.

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