Lindsey Bishop

Quality Management - NSP 3885

Professor Bell

Winter 2018

Video Briefing Script

 Medication Safety

The practice of medication safety is quite self-explanatory. It is the act of preventing

medication related error and promoting safe medication use. Medical errors relating to

medication, adverse drug reactions, and incorrect use of prescribed medicine could potentially

impact the health outcome of patients and may contribute to longer hospital stays, increased

incidences of hospital readmission rates, harm, and sometimes death.

Promoting and practicing medication safety is a responsibility shared by all medical

professionals, health care organizations, and patients, in every healthcare setting. There are

various ways to improve and ensure medication safety in inpatient settings, including the

implementation of electronic safeguards and the utilization of effective communication

techniques (Healthcare It News, 2018). At home, patients can practice medication safety by

becoming better educated on the prescription drugs they are taking and ways to prevent adverse

drug reactions from occuring (Sharp Healthcare, 2015). Improving medication safety in inpatient

settings and at home is absolutely essential.

Medication Safety in Inpatient Settings

Medicinal error in an inpatient setting is largely due to mistakes made by medical

professionals themselves. In 2006, Emily Jerry, a two year old girl, was receiving her final

chemotherapy treatment in her fight against cancer when a medication-related error killed her.

The medical professional in charge of Emily’s treatment administered the incorrect dose of the

intravenous solution to Emily, sadly ending her life (Healthcare It News, 2018). A medicinal
mistake, like the one that cost Emily her life, could occur at any point during the process of order

transcription or the administration of medicine. A physician ordering the wrong prescription, a

dispensary error at the pharmacy, and a medical professional administering the incorrect

medication to a patient are few example of errors that can be made during the course of treatment

in an inpatient setting (Healthcare It News, 2018). To promote the practice of medication safety,

we must address the incidences of medication-related mistakes through implementing safeguards

in the healthcare system as a whole, instead of pointing the finger at just one culprit (Healthcare

It News, 2018). Practicing effective communication and implementing safeguard technologies

into hospitals and other inpatient settings may substantially reduce the incidences of error related

to medication.

Recommendations for Improvement

When effective, communication can aid in eliminating many instances of medication

related harm. In an inpatient healthcare setting, the establishment and promotion of open

communication is a vital component of fostering care that is focused on providing customers, or

patients, with quality healthcare (Goetsch & Davis, 2016. p. 94). The many moving parts of the

medication transcription and administration process of any inpatient facility can create a

significant and dangerous communication barrier (Healthcare It News, 2018). Practicing

effective communication amongst the departments involved in the drug transcription and

administration process could inherently prevent many occurances of harm, therefore increasing

medication safety. When completing patient forms, or prescribing medication, the practice of

self-editing, or double-checking, is essential to ensure that the information being recorded is

accurate (Goetsch & Davis, 2016. p. 168). Keeping other employees regularly up-to-date on

information regarding a patient can also be impactful when avoiding communication errors
(Goetsch & Davis, 2016. p. 170). These are just few examples of effective communication

practices that can largely contribute to medication safety within an inpatient settings.

To further prevent dangerous medicinal mistakes, implementing electronic safeguards to

curb human error may help enhance medication safety. Examples of these safeguards include

computerized physician order systems, dispensing systems, inventory management systems, IV

workflow technology, and barcode verification technology (Healthcare It News, 2018). A 2010

study aimed to evaluate the effectiveness of implementing barcode verification technology

within an electronic medication-administration system, or barcode eMAR, in 35 departments of

a academic medical facility (Poon et al. 2010). A technology that Chris Jerry believes could have

easily prevented the death of his two year old daughter, Emily Jerry (Healthcare It News, 2018).

By using the barcode eMAR technology, nursing staff can ensure the correct medication and

dose of medication is given to the specified patient at the correct time by scanning the barcode

located on the patient’s admission bracelet. This technology could cut down on the instance of

manual error in the traditional paper-driven prescription process (Poon et al. 2010).

Researchers observed the process of medication administration both before and after

implementing the barcode eMAR technology. Of 6,723 medication administrations observed

before the implementation of the technology, 776 errors were observed. Of 7,318 medication

administrations observed while utilizing the barcode eMAR technology, only 495 errors occurred

(Poon et al. 2010). Although the bar-code verification technology did not completely cease the

instance of error, it did significantly lessen it. Combining useful electronic safeguards like

barcode eMar technology along with fostering open communication can greatly improve

medication safety in inpatient settings.

Medication Safety at Home

For some time now, the national conversation in the United States has been centered

around the topic of medication safety and opioid abuse. It is commonly known that many

individuals who are prescribed opioids become addicted and dependent upon the medication,

sometimes accidentally. It is important for patients to educate themselves on the medications that

they are taking, as well as how to manage their prescriptions responsibly, so events like addiction

and adverse drug reactions can be prevented. An adverse drug reaction is any unintended harm

that occurs from medication use (Sharp Healthcare, 2015). An adverse drug reaction can occur

by mistake, when patients take the wrong dose of medication, take a medication at the wrong

time, forget to take a medication, or stop taking a medication before the indicated date. Those

who have a greater risk of experiencing an adverse drug reaction include children, adults over the

age of 65, or any individual taking more than four medications (Sharp Healthcare, 2015).

Recommendations for Improvement

Patients can also play an active role in protecting themselves against adverse drug events

and other medication-related harm. Comprising a list of all prescribed medication can lower the

chances of an error in communication or medicinal harm. The list should include the following

information:

● The name of each medication

● How it is administered

● Time of administration

● When it was prescribed

● The name of the physician that prescribed each medication and their contact

information
Bringing the list of medications to all medical appointments and pharmacy visits can greatly

increase the chances of detecting and preventing adverse drug events or medication errors from

occuring (Sharp Healthcare, 2015). Patients that consistently record the information above are

actively practicing medication safety.

CONCLUSION

The betterment of the practice of medication safety is more important now than it has

ever been before. With medication usage becoming more complex in recent years, ensuring

medication safety must become a responsibility shouldered by all healthcare professionals and

patients. Improvement efforts must be made by all parties involved to protect patients from

harmful and life-threatening medicinal mistakes both in inpatient settings and when taking

prescription medication at home. Implementing technology to reduce human error, actively

partaking in concise communication techniques, educating oneself about the prescription drugs

they take, and responsibly keeping track of the information associated with each drug, are just

few examples of how medication safety can be improved in both inpatient settings and at home.

References

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., ... &

Churchill, W. W. (2010). Effect of bar-code technology on the safety of medication

administration. New England Journal of Medicine, 362(18), 1698-1707.

Sharp Healthcare (Producer). (2015). Medication safety tips: how to prevent adverse drug events

[Video file]. Retrieved from https://www.youtube.com/watch?v=JU-70DibqU0

Goetsch, D., & Davis, S. (2016). Quality Management for organizational excellence:

introduction

to total quality. Boston, Massachusetts: Pearson Education

(2018, January 21). Medication safety falls previously short of patient expectations. Healthcare

It

News. Retrieved from http://www.healthcareitnews.com/news/himss-analytics-survey-

medication-safety-falls-perilously-short-patient-expectations