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PAPER English for Nurses III MEDICATION ERRORS Yunita Safitri (0806323252) Class B Group 4

Medication errors, broadly defined as any error in the prescribing, dispensing, or administration of a drug, irrespective of whether such errors lead to adverse consequences or not, are the single most preventable cause of patient harm. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. The majorities of medication errors occur as a result of poor prescribing and often involve relatively inexperienced medical staffs, who are responsible for the majority of prescribing in hospital. Electronic prescribing may help reduce the risk of prescribing errors owing to illegible handwriting, although such systems can in turn lead to further problems such as incorrect drug selection, and their effect on patient outcomes requires further study. Experts estimate medication errors are a leading cause of death and disability. More people die annually from medication errors than from workplace injuries. Some studies suggest that physicians, administrators and nurses perceive patient safety as primarily a nursing responsibility. Because nurses take a central role in patient safety, there is a danger that errors can be attributed to nurses rather than to system failures. However, evidence shows that nursing vigilance protects patients against unsafe practices. For example, one study showed nurses were responsible for intercepting 86% of all medication errors made by physicians, pharmacists and others before the error occurred. A system - wide approach that involves all members of the health care team as well as management, is a sound approach for patient safety. Every step in patient care involves a potential for error and some degree of risk to patient safety. Today’s complex health care system can create some issues about patient safety. A proper understanding of the factors that increase medication errors is the first step in preventing them. In a study of prescribing errors, the most common factors associated with errors included:
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Using the wrong drug name, dosage form, or abbreviation; Mistakes on calculating dosage; Atypical or unusual and critical dosage.

As with other safety issues, medication errors arise from human errors and/or system failures. Medications errors may, therefore, result from problems in practice, products,

Other factors. and of the patient details contribute to prescribing errors. Confusion with the drug name. Incidence of Medication Errors Incident rates of medication errors vary widely. such as training deficiencies. Characteristics of Medication Errors The three most frequently reported types of errors are: o o o o o o Omission errors (failure to administer a prescribed medication). 1·0).g. Table 1: Types of Medication Errors Types extra dose improper dose/quantity Contributing Factors distractions workload increase Causes performance deficit procedure/protocol not followed . the reason for which can be explained by the different study methods and definitions used. strength. 0·1). An analysis of medication errors can help healthcare professionals and managers to identify error-prone medications or categories of drugs. AZT has led to confusion between zidovudine and azathioprine). Medication error has been estimated to kill 7. Inappropriate use of decimal points. The rate of medication errors varies between 2 and 14% of patients admitted to hospital. and the majority are due to poor prescribing. Use of abbreviations (e. tenfold errors in dose have occurred as a result of the use of a trailing zero (e. with 1–2% of patients in the US being harmed as a result. Other contributing factors include: Illegible handwriting.procedures or systems.g. Similarly. Medication errors (7% of all incidents) were the second most common incident reported (after patient falls) in a recent National Audit Commission report on patient safety. undue time pressure and poor perception of risk can also contribute to medication errors. Inaccurate medication history taking.g. its recommended dose. Lack of knowledge of the prescribed drug. Improper dose (medication dose. Unauthorized drug errors (the medication dispensed and/or administered was not authorized by the prescriber).000 patients per annum and accounts for nearly 1 in 20 hospital admissions in the US. or quantity different from that prescribed). and make improvements to prevent or reduce them. The incidence is likely to be similar in the UK. A zero should always precede a decimal point (e.

2. An approach that is commonly used in human factor analysis is a critical incident analysis. as voluntary reporting of adverse events provides data that leads to improved patient safety. although reducing the error rate significantly will require multiple interventions and close collaboration between the health team and management. why the incident occurred. Health care organizations and health professionals should be encouraged to participate in voluntary reporting systems as an important component of their commitment to patient safety. provides an understanding of the conditions that produced an actual error or the risk of error as well as the contributing factors. whether or not the event actually leads to a bad outcome. and the circumstances surrounding the incident. Feedback and dissemination of information can create an awareness of errors that occur in the system and improve system design to reduce or eliminate medication errors. . Sufficient attention must be given to analyzing and understanding the causes of errors in order to create learning systems and improve patient safety. This analysis examines adverse events to understand where the system broke down. Vol. 2 No. Analyzing critical incidents.omission error prescribing error unauthorised drug wrong administration technique wrong dosage form wrong drug preparation wrong patient wrong route wrong time inexperienced staff shift change agency/temporary staff no 24 hour pharmacy insufficient staffing emergency situation cross coverage code situation no access to patient information knowledge deficit inaccurate or lack of documentation confusing communication inaccurate or omitted transcription computer entry drug distribution system inadequate system safeguards illegible or unclear handwriting (Source: Ruth M. Nursing Spectrum. A good way to learn from medication errors is to establish a reporting system.39) Medication errors are preventable. because of the “blame and shame” approach in health system. Kleinpell. p. February 2001. Reporting errors is only the first step in the process of reducing errors and continuous quality improvement. However. there is generally underreporting and what is reported is often the tip of the iceberg.

Creating a culture of safety does not just mean eradicating the culture of blame but also involves changing the entire way one thinks about and approaches the work in the medication cycle. The problems. Clarification of terminology in medication errors: definitions and classification. .ac.104.org/ aboutMedErrors.Aronson JK. American Journal of Nursing. emphasizing the need to improve prescribing skills. 2010. this is what is required in order to create a culture of safety in order that one can understand what causes medication errors and implement systems to prevent them recurring. 2007.pdf accessed March 23th. (2004).32-43 Ferner RE. 2010 Anonymous. K. Medication use systems can be made safe by making them resistant to error and by adding important checks and controls. “Medication Errors”. Drug Saf 2006. Style sheet : http://www. 29(11):1011–22. 2010 Anonymous.All healthcare professionals have a responsibility in identifying contributing factors to medication errors and to use that information to further reduce their occurrence.nccmerp. A non-punitive approach should be adopted to improve the rate of reporting of medication errors.. Whilst it may seem counterintuitive to reward people for reporting failures.6. No. A.. and Clare. Style sheet : http://www. “Medication Errors”. An Error by any other name.gov/Drugs/DrugSafety/ MedicationErrors/default. The majority of medication errors occur as a result of poor prescribing. 2010.icn. Style sheet : http://www. We must recognize that the current approaches to preventing medication errors are inadequate and require a shift in emphasis to a scientific investigation of preventable patient harm.uk/journal/ issue/journal_37_4/Williams. References: Anonymous. Unfortunately the difficulties associated with making systems failsafe explain the significant number of medication errors that continue to occur. confidential. “Medication Errors”. allowing further investigation of these important causes of preventable patient harm. Significant increases in the reporting of medication errors have been noted where confidential. Key Points: Medication errors are one of the most preventable causes of patient injury although the incidence of such errors varies widely as a result of differing definitions and methodologies. Guttmannova. sources and methods of avoiding medication errors are multi factorial and multidisciplinary.fda.htm accessed March 23th. Vol. 2010 Cook. Style sheet : http://www.ch/matters_errors. no-fault reporting has been implemented.html accessed March 23th. F. non-punitive reporting has its faults including the fact that the true number of medication errors will still not be known and that confidential reports may be difficult to validate. “Medication Errors”.htm accessed March 23th. 2010 Anonymous.rcpe. However. pp. 2009. A multidisciplinary approach to solving the problem of medication errors needs to be taken.