Posted: March 18th, 2024

Medication Errors: Causes, Consequences, and Prevention

Medication Errors: Causes, Consequences, and Prevention
1. Introduction
The first major section delves into the causes of medication errors. It discusses both human factors, such as cognitive limitations and communication breakdowns, as well as system factors, including medication packaging and labeling issues. The next section focuses on the consequences of medication errors. It highlights the harm caused to patients, such as adverse drug reactions and even death. Additionally, it explores the economic burden associated with these errors, including increased healthcare costs and legal expenses. The final section explores prevention strategies for medication errors. It emphasizes the importance of education and training for healthcare professionals to improve medication management practices. It also discusses the role of technology and automation in reducing errors, such as computerized physician order entry systems and barcode scanning technology. Overall, this study provides valuable insights into the causes, consequences, and prevention of medication errors, ultimately aiming to improve patient safety and healthcare outcomes.
1.1 Background
The term “medication error” is used to define different types of events, such as administering the wrong medication, giving a medication at the wrong time or in the wrong dose, or forgetting to administer a dose. Medication errors occur at any stage of the medication use pathway, from prescribing to dispensing and administering, and in any healthcare setting. For patient safety, it is critical that medication errors are notified, recorded, and acted upon appropriately. Prior research has shown that there are a number of factors that can contribute to medication errors. These include inexperienced staff, staff with heavy workloads, insufficient training, errors in verbal communication between staff, the storage of drugs, and the use of handwritten medical records. However, the evidence is far from consistent, and the causes of errors are likely to be complex and multifaceted. Medication errors can result in a patient receiving suboptimal medical therapy or suffering harm as a result, and they can also increase the cost of care. Many different things have been shown to be effective in helping to reduce levels of medication errors, from having the right equipment and an appropriate working environment through to providing staff with training and feedback on their work. However, the importance of these different factors and the reasons it may be effective have not yet been explored fully.
1.2 Scope of the Study
The second component of the introduction provides an overview of the scope of the study. It explains that the research will explore various topics such as different types of medication errors, where errors are likely to occur, and who is generally found to be at fault in these cases. From the beginning, the accessible literature on the topic is detailed and critiqued. By highlighting the previous findings and recommendations, the introduction then focuses on discussing the aims and objectives of the current study. The paper argues that contemporary health policies increasingly define patient safety as a quantitative, measurable phenomenon, focusing on criteria such as hospital mortality and the incidence of specific adverse events. Through comparing the United Kingdom health policy with those in other countries, the authors seek to tell an international story of increasingly standardized, quantitatively driven approaches to patient safety and, in doing so, to make a global argument about the changing politics of patient safety and professional accountability. The research aims to investigate the ways in which successive United Kingdom health policies have variously presumed both that the environment of care can largely be standardized and rationalized, and that the prime obstacles to achieving this are the attitudes and working practices of healthcare staff. The caveats of this approach, which favors managerial control of potential risk and clinical errors, are considered in the context of the current Government’s emphasis on the modernisation of the National Health Service. Lastly, it is shown that there is a rhetoric of blame and managerialism surrounding patient safety, with an emphasis on the need for cultural change among healthcare professionals. The research will consider the extent to which these policies have holistically embraced patient safety, or, as the paper will argue, have attempted to harness contemporary discourses of patient-centered care as part of a wider project of healthcare modernisation and government-led introduction of private sector discipline into the public health system.
1.3 Research Questions
Secondly, the second and third resources are very important to support our defined strategies (in 3 tiers of analysis) focusing on the adoption of modern technology for community profiling. From the second resource, we can focus our writing on how the social determinant approach for mental health and wellbeing advocates and emphasizes the needs of “Real People, Real Solutions: social determinants of health in practice.” This can be further justified by “the potential power of health informatics and the uses of information and communication technology to…” As the mental health article provides sophisticated analysis by employing the Geographical Information System and other spatial technology methods, we can share the same view that technology provides comprehensive tools that analyze the complexity and variety of different population groups in society. We can constantly remind the reader that the mental health paper is supporting the statement and justification that we put in our writing, and hopefully, the marker will strongly agree with our selected 3 tiers of analysis if our justification is strong and consistent throughout the literature review.
The first resource can be used to define community profiling, which is required to be done from a demographic approach, a social approach, and a business and investment approach. By this definition and the interactive elements provided in the paper, we can explain how the demographic indexing proposed in the document can be interrelated with the Health Intelligence Tool and the Geographic Information System, and how the knowledge obtained from the Public Health Analysis can be put into serving the business and investment diversity.
Firstly, we can provide three direct resources in our 3 tiers of analysis. They are “Community Profiling – an Australian Approach,” “Social Determinants of Health: the Community as Brand,” and “A Model of Risk for Mental Health and Wellbeing: Lessons from an Australian Community Survey Medical Journal.” All these articles are published in Australia and their focuses are on community profiling, social determinants of health, and mental health. As most of our team members are staying in Australia and planning for our SLP in a local context, we believe that the resources are relevant to our research topic and research questions.
2. Causes of Medication Errors
The first conclusion is that employees have an unrestricted access to controlled substances such as Xanax, OxyContin, and Ritalin, and pharmaceutical staff can easily get their hands on these substances and abuse them as demonstrated in this case. Although all staff have access to the cabinet where the medication is located, none of the employers were able to explain why the cabinet was not locked throughout the shift, which could have prevented these errors. It is not clear from the case how often the controlled substances record is checked. Most states require weekly review of the list of the patients who received controlled medications and which staff administered the drugs. This means that these kinds of errors should have been identified when the controlled substances record was checked. Also, this situation is not consistent with the American Nurses Association’s view that the workplace should be a place where the respect for human being is the characteristic and any type of threat to one’s dignity should be eliminated. The American Nurses Association emphasizes the principle of “primacy of the patient’s interest” and “the right of the patients to self-determination,” which states that each nurse should respect the dignity and right of patients. Every employee has a duty to maintain the patients’ trust and confidence and to promote a partnership between a patient and society. It is easy to recognize that medication errors as a result of some form of threat in the workplace, which reveals that the employers have failed to maintain such a dignified workplace for all staff. Finally, this case has been brought to the Office of the Prosecution; however, whether criminal charges will ensue or the level of penalties if found guilty are unclear from the case. Also, I cannot find any information up to date that is relevant to this case, such as what punishment did the staff in question receive from the court and did the clinic resolve this issue.
2.1 Human Factors
When talking about human factors and medication errors, it is quite easy to quickly point the finger at the care providers directly involved in the administration of the medication. However, human factors is the study of how humans behave and interact in the working, and how this can influence the people and the environment around them. Because of this, when we refer to “human factors”, what we are really talking about is the different ways that humans’ work can be intrinsically affected by fundamental attributes such as fatigue, individual characteristics like approach to risk and also the team’s response to the effect of working with others. This is particularly relevant in the healthcare setting, where busy workers are concentrated on constant demands that require a combination of varied tasks, teamwork, individual interactions and the use of highly specialized technology. As a result, the scope for the risk of error through failure or mistake is incredibly large. For example, administering medication is a frequent task in the medical environment and one that comes with a high risk of an error occurring. From the very start of dispensing the medication, through to the patient taking the medication, there are various critical checkpoints where an error can have a significant impact on the patient and those involved in their care; a prescribing error from a doctor, misinterpretation by the pharmacist, mistakes during the preparation, or errors at the time of medication being taken by the patient. With technology evolving and being continually integrated into the medical environment, automation is often brought up as the solution to reducing these human factors and subsequently reducing the risk of medication errors. However, machines and technology will not be able to address many of the complex interactions between the different stages and individuals involved in the administering of drugs; in fact, due to this “automation bias” – the tendency for humans to take the word of a technological device as accurate, even over their own perceptions and judgments – the introduction of technology can sometimes actually increase the risk of an adverse event occurring due to the mutual reliance on the automated elements.
2.1.1 Fatigue and Workload
2.1.2 Lack of Communication
2.1.3 Distractions and Interruptions
2.2 System Factors
The design of the workplace can have a huge impact on how medication is stored, prepared, selected and administered. Poor environmental factors such as bad lighting can make it difficult to read labels; lack of space can lead to drugs being stored inappropriately. In addition, the use of equipment and technology in the medication process creates the potential for both use errors and knowledge deficits to cause harm. For example, similarly designed equipment and poor labeling can lead to selection errors. Onscreen prompts to alert the prescriber to potential problems associated with a prescription have been introduced in a number of instances as measures to prevent errors at the prescribing stage. However, research into the effectiveness of this kind of support finds that they are often overwritten by prescribers and some can produce new errors. This is a concern echoed in the prevention strategies to follow on from this study. Sadly, it is clear that most medication errors are made not by individuals but by teams; it is easy to say a better-educated nurse might reduce their personal errors but it requires a better-educated and better-designed system to combat the majority of medication errors.
2.2.1 Inadequate Technology and Automation
2.2.2 Poor Medication Labeling and Packaging
2.2.3 Complex Medication Regimens
3. Consequences of Medication Errors
Patient harm related to medication errors can be classified into two broad categories – adverse drug events and preventable adverse drug events. Adverse drug events are harm experienced by a patient as a result of exposure to a medication, whereas preventable adverse drug events are those that occur because of a medication error. Studies have shown that medication errors are a leading cause of morbidity and preventable adverse drug events in the healthcare system. As a result of such events, patients may suffer from prolonged hospital stay, temporary or permanent disability, and even death. For example, one study investigated the impact of medication errors on patients who have chronic kidney disease. The researchers found that approximately one in every five medication orders for these patients contained at least one dosage of the medication that exceeded the recommended level. As a consequence, the patient’s renal function could be severely compromised. Such examples highlight the potential dangers associated with medication errors, and the results of many studies suggest that the majority of cases are considered preventable. Economic burden refers to the financial impact of an event on a society. Medication errors can have significant financial implications for both individual patients and the wider healthcare system. If medication errors result in a patient being admitted to hospital or in an extension of their hospital stay, this has the immediate impact of increasing healthcare costs. Studies have suggested that as much as 20% of preventable adverse drug events could lead to a patient requiring extra healthcare resources, including hospital admission. In 2013, an investigation estimated that the cost of medication errors in secondary care in the UK was around £750 million. These costs are associated with extra prescribing, monitoring, and investigations that may be required as a direct result of a medication error. In the long term, litigation costs and compensation payments should also be considered – particularly since the economic impact of medication errors can actually be greater than the costs directly associated with patient care. Scary truths, indeed!
3.1 Patient Harm
During the summary of the work “Medication Errors: Causes, Consequences, and Prevention,” it is presented as the work starts with an introduction, providing background information and defining the scope of the study. The research questions that will be addressed are also presented. The causes of medication errors are discussed in detail, with a focus on both human factors and system factors that contribute to these errors. Human factors pertain to the acts or behaviors of healthcare professionals that may lead to medication errors, and system factors are things that are not in the control of humans, unlike human factors. This is interesting as we can see that the author is taking us on a journey, slowly focusing more and more on specific aspects of the topic from the broad causes of medication errors as a whole. This indicates that patient harm is among the serious consequences as described in the previous contents. Patient harm can range from minor adverse reactions to severe injuries or even death. Additionally, the economic burden of medication errors is highlighted, as these errors can result in increased healthcare costs and legal expenses. The author has used pragmatic language and a formal style, which is effective for the topic as it is a scientific and serious one. There is reference to education and training programs that are recommended to improve healthcare professionals’ knowledge and skills related to medication administration. These supporting points will form the basis of the third paragraph and the exploration of the preventative measures of medication errors. Overall, this article provides a comprehensive overview of medication errors, their causes and consequences, and suggests prevention strategies that can help mitigate these errors. The writer has used heavy and serious topics which reflects the seriousness of the medication errors, and the comprehensive nature of the research and recommendations provided gives the piece an informative feel. The organization and unpacking of the research questions one by one create a good journey, and by investing in that, the piece comes across as more persuasive.
3.1.1 Adverse Drug Reactions
3.1.2 Medication-related Hospitalizations
3.1.3 Long-term Health Effects
3.2 Economic Burden
The economic burden of medication errors is a major concern for healthcare systems and insurers, as these errors can result in avoidable costs. For example, the costs associated with an extended hospital stay, further treatments to address complications, and legal fees from malpractice lawsuits can lead to a significant financial impact. Studies have estimated that the total annual cost of medication errors in the United States is over $20 billion, with the additional healthcare burden resulting in over 500,000 additional patient days in hospital, or about 1.2 million emergency department visits. These costs can be attributed to a variety of factors, from increased use of healthcare resources to decreased productivity and lost wages. For instance, a research study found that the annual cost of lost productivity and lost wages resulting from fatal medication errors reached nearly $1.6 million per event. Furthermore, this cost was unlikely to be fully reduced, as the same study found that more than half of these patients were retired, removing their lost wages from the total value. In another example, analysis of cases in one year in the United Kingdom found that the introduction of e-prescribing systems reduced serious prescribing errors by 44%, potentially preventing 1 million serious errors in that time. Such technology has the potential to reduce both the probability of medication error and the severity of the error, as well as to reduce the awareness and diligence required to ensure the correct medicine is given. This will reduce the associated future costs of medication errors on both the patient and the healthcare system and so may lead to less reliance on human administration and monitoring. This suggests that not only can the health of the patient improve, but the costs of medication errors on healthcare systems can reduce with appropriate preventative technology. The article “Medication Errors: Causes, Consequences, and Prevention” provides an overview of the topic, focusing on the different aspects related to medication errors. Overall, this article provides a comprehensive overview of medication errors, their causes and consequences, and suggests prevention strategies that can help mitigate these errors.
3.2.1 Healthcare Costs
3.2.2 Legal Expenses
3.2.3 Lost Productivity
4. Prevention Strategies
The next section will be focusing on the prevention strategies for medication errors, particularly in relation to patient harm reduction and standardizing best practices across the healthcare system. At the forefront of the prevention strategies is the creation of a non-punitive culture and a focus on the positive aspect of medication error reporting. This involves the implementation of what is known as ‘just culture’ – a culture of safety, quality, accountability and trust; which encourages healthcare professionals to report medication errors without fear of punitive actions, if the error is due to system failures or human error. According to the Institute for Safe Medication Practices (ISMP), the strategy helps to provide valuable information on when and where system improvements are needed to prevent future errors and allows learning to take place. This is supported by the findings of an observational study conducted by Morimoto et al., in a University of Chicago hospital where the implementation of a just culture for medication error reporting showed substantial decrease in the number of serious medication errors reported and an increase in the number of reported errors from physicians and nurses. Another prevention strategy highlighted in the study is the adoption of “better use of information technology” by the newly formed US Patient Safety and Quality Improvement Act, passed in July 2005, which encourages the application of evidence-based information for safer medication use. Also, the Act established Patient Safety Organizations which will specifically focus on identifying and reducing hazards associated with medication use. As technological advances in patient management and pharmaceutical industries keep progressing, the study believes that automation and other latest technological advances have increasingly played vital roles in minimizing medication errors. This would include the use of electronic medication administration records which nurses can access real-time patients’ medication records and generate alerts for any wrong medications given; as well as the implementation of “unit dose system” wherein medications are prepackaged by pharmacies according to a 24-hour supply and dispensed in patient-specific dose bins. However, technology itself is not the panacea for medication errors. The study highlighted the need of healthcare professionals to be aware and understand the capabilities and limitations of technology, in supporting and enhancing patient care and reducing medication errors. In another word, “new technology should be viewed as augmenting professional capabilities, not replacing them.”
4.1 Education and Training
In relation to the entire study, we now move to a discussion of strategies to prevent medication errors. What is very important to mention is the fact that the prevention strategies are used and therefore should flow from the previous section which outlined the consequences of medication errors. We first of all have a look at education and training. This is where all healthcare workers who are involved in any step in the medication process, from its initial prescription by the doctor right up to the point of the patient taking the medication, are educated and trained about the importance of medication safety and how errors can be reduced. For instance, new doctors have to undergo a number of years of supervised training after they have graduated in order to make sure that they are trained on a regular and consistent basis. And then it does not stop there. They must do continuous professional development in order to keep up to date with new research and developments in prescribing. Pharmacists are taught about the huge range of different medications, what they are used for, common doses etc. Nurses also have to show that they understand and are able to apply this knowledge in practice. Over and above this general nursing teaching, many nurses may choose to have special training in the use of medications in a particular field of nursing. For patients, there is a balance between their own personal responsibility for their healthcare and the information that healthcare providers are expected to give them in terms of keeping them safe. It’s an individual’s own right to accept or refuse any medications and also to choose whether to seek medication treatment but it is important that healthcare providers give the patients the information they need to make a balanced and informed choice. Also, by doing this you may reduce prescribing errors which occur due to a lack of information on a patient’s medical history. The idea is that this sort of prevention plan actively engages the patient in their own care and so reduce the likelihood of medication errors.
4.1.1 Healthcare Professionals
4.1.2 Patients and Caregivers
4.2 Technology and Automation
The potentially pivotal role of technology and automation in reducing medication errors has gained increased attention and prominence in recent years. Technological advancement could be seen with the rapidly evolving computer processing power, the continuous improvement in data storage capacity, and the emergence of groundbreaking technologies, such as artificial intelligence, machine learning, or big data. Automation and technology can be employed in different stages of the medication management process, ranging from the prescription of the medication to the final administration of the medication to the patient. For instance, with the utilization of an electronic prescribing system, prescribers could now directly transmit the prescription to the pharmacy. Software in the system could be equipped with a clinical decision support tool, providing prompt alerts to the prescribers if any potential error is detected, such as allergy to the medication or drug-drug interaction. Automation in the medicine dispensing process with the use of pharmacy robots and barcode technology could greatly minimize the occurrence of medication errors that are attributed to the dispensing process nowadays. By interacting with the barcode on the medication package, the barcode scanning system at the point of care could instantly access the medication profile of the patient and provide real-time decision support, which ensures the “five right” of medication administration is achieved: right patient, right drug, right dose, right route, and right time. The use of technological advance and innovative solutions in the improvement of patient safety has been strongly encouraged and supported. Over the years, numerous hospital accreditation bodies and professional healthcare organizations are actively promoting and recognizing the meaningful use of technology in achieving high-quality healthcare and patient safety. For example, the Joint Commission has established the ‘Gold Seal of Approval’ program to elevate the standard of healthcare by advocating healthcare organizations to utilize electronic health record and clinical decision support systems. With the changing global landscape in healthcare where high quality, effective, and safe care is one of the main objectives for all healthcare providers, it is anticipated that technology and automation will indeed revolutionize the practice of medication management and will eventually replace the traditional, paper-based approach. Coupled with appropriate legislative and financial support, healthcare providers and organizations should embark on the journey to explore and embrace technology and automation in their practice to explore the full potential of the tools in reducing medication errors. On the other hand, it should be acknowledged that utmost caution must be taken in the implementation of these technologies. Cybersecurity threat has become a main concern for many healthcare providers, and recent researchers have revealed that many electronic health record systems are falling short in terms of data security. Besides, without proper support and thorough training for the staff, technology could bring about new sources of error in the practice. Therefore, it is of paramount importance that healthcare providers remain vigilant in monitoring and enhancing the system reliability and data security while staff are kept up-to-date and well-trained when new technology is introduced into the practice.
4.2.1 Electronic Prescribing Systems
4.2.2 Barcode Medication Administration
4.2.3 Clinical Decision Support Systems

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