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Medication Errors

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Medical errors have and continue to be an enormous problem in health care. Patients die from the wrong drug or wrong dosage, or perhaps an infection that could have been prevent with better hygiene practices. More attention was placed on the issue of medical errors in 2000 when the Institute of Medicine made available the well-known report titled “To Err is Human: Building a Safer Health System”. The report documented evidence of an estimated 44,000 people and as many as 98,000 people dying in hospitals from medical errors each year in the United States (IOM, 1999). Of the many medical errors, medication errors happen to be one that can not be overemphasized. Medication use have been found to account for at least 20 percent of adverse events in patients in hospitals. Out of every hundred medication orders, there is an occurrence of five adverse drug events (Tam, 2005).

Malpractice claims due to adverse drug events can have negative effects on the hospital and the health care providers. The hospital and health care providers can have their reputation damaged, thousands of dollars are spent for the losses, there is time lost from work, not to mention the emotional stress involved (Rothschild et. al, 2002). The cost of preventable medication errors has been estimated between 17 and 29 billion dollars annually (Strohecker, 2003). As such, due to these alarming statistics, this paper focuses on some of the potential risks of medication errors, and some recommended interventions that can be implemented to help curb the incidence of medication errors.

Many of the factors leading to medication error are unfortunately human related (Etchells, et. al, 2008). A survey of 983 nurses working in acute care hospitals reported that among the many factors that would contribute to medical errors, illegible hand written prescriptions, distraction from the environment, exhaustion and stress happened to be the most weighted (Mayo & Duncan, 2004). A study by Hodgkinson et.al that sought strategies to reduce medication errors cited the most common reason of medication error was due to the lack of drug information by the multidisciplinary team (2006). Inexperience and or lack of knowledge of the drug could lead to the physician ordering the wrong dose, the pharmacist incorrectly mixing the medication with the right concentration, and the nurse administering the medication with the wrong route such as giving an intramuscular injection instead of subcutaneously (Etchells, et. al, 2008).

While human error is very important to consider, it is equally important to analyze the context in which errors can occur such as the clinical environment and patient population. The type of clinical setting in a hospital can be more prone to medication errors than others due to the patient population with respect to the severity of their illness, and number and type of medications needed to be administered. Critical care units for example, tend to be at a higher risk for medication errors. Critical care units provide for very sick patients who need to be attended to without delay, may require consults from various providers, and receive twice as many medications as compared to patients on general medical floors. Patients in intensive care experience an average of 1.7 medical errors each day. Medication errors are the most common type or error and account for 78 percent of serious medical errors in critical care (Camire et. al, 2009).

In addition to the patients in critical care, pediatrics and the elderly also tend to be at high risk for medication errors since there require many medications when sick. Pediatric patients in particular tend to be very sensitive to most medications hence the need to calculate most of their medication dosages by weight (King, 2003). The least miscalculation could lead to an adverse drug event. Older adult populations, on the other hand, take many prescription medications for their chronic illnesses which need scrutiny to avoid contraindications (ANJ, 2009). However, regardless of whether the patient may be at risk of experiencing a medication error or not, all medication administration must ideally follow the “seven rights” which include “the right patient, right medication, right dose, right time, right route, right reason, and right documentation” (Schaeffer, 2009).

With medication errors responsible for many lost lives yearly, new national patient-safety standards require hospitals to have a mandatory formal medication reconciliation process for every patient admitted into the hospital. Medication reconciliation would take effect during the patient’s admission process and involves the recording of a patient’s allergies and thorough collection of all the patient’s home medications including over the counter drugs. This routine has been found to reduce medication duplication and avoid the effects of contraindication while the patients are hospitalized. This also aids the physicians on what medications to discharge the patient with. During the medication reconciliation process the need to educate the patients and their families is also import. Patients and families have to understand the rationale behind keeping handy a list of all their medications and being able to provide the list especially in emergent situations (Landro, 2006).

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