CAUSES OF MEDICATION ERRORS:

Medication errors are caused by many factors. “To Err Is Human” was so named because it is
normal for human beings to make mistakes. The culture of healthcare held the belief that
physicians, nurses, and pharmacists are so well educated that they would not make mistakes if
they were careful. Human beings, even healthcare professionals, make mistakes 2-5% of the
time, especially when doing repetitive task. The error rate increases when they are tired or
hurried.
Root Cause Analysis (RCA), a method used to investigate an error. It is used by industry but
recently been applied in healthcare settings. In performing RCA, it involves an individual or a
team analyzing all the steps leading to an error event. With that, three types of factors are
analyzed: human, organizational, and technical. Human factors involved one or more persons
causing the error, can be uncovered through nonthreatening interviews. Organizational factors
include structural problems, such as insufficient staff, inadequate supervision, or inadequate
training for a task. Technical factors include having to work with malfunctioning equipment. All
of these factors are analyzed in detail. The final critical step with any RCA is to ensure that the
recommendations for improvement are put in place and maintained.

PHARMACISTS’ ROLES IN MEDICATION SAFETY:

Pharmacist’s contributions in preventing medication-related problems for adult and pediatric
patients in both inpatient and outpatient settings is well documented. Pharmacists helped prevent
adverse consequences through medical record review. For patients being discharged from the
hospital, pharmacist counseling has helped prevent adverse drug events after they leave the
hospital. However, the current pharmacist shortage is having a negative impact on medication
errors.
Pharmacist’s role is expanding with the advancement of informatics technology and the
increasing demand for electronic health record systems to continue efforts of medication error
prevention. Pharmacists are needed to contribute their expertise in drug management through
designing and implementing healthcare informatics tools. Also, pharmacists can help develop
informatics decision-making tools and medication safety features designed to prevent errors.
Computerized tools, in turn, enable pharmacists to expand their consultation potential and
improve the quality of healthcare services to patients.