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Assignment: Risk Management

MO FAIZAN ALTAFHUSEN KURESHI

STUDEND ID: 000931803

Southern Alberta Institute of Technology

HCAR-403-HJA: Healthcare system and Governance

5 APRIL 2024
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Introduction

A medication error is an unexpected failure in the medication treatment process that

causes harm to the patient or can cause harm. The most frequent avoidable cause of undesirable

adverse events in medication practice is mistakes in the prescription, dispensing, storing,

preparation, and administration of a medicine. These errors also pose a significant public health

cost. (European Medicine Agency, nd)

Consequences of Medication Errors

 Adverse patient health outcomes: According to studies, approximately 20,000

hospitalized patients and 5,000 deaths occur in Canada each year as a result of

medication errors. Medication mistakes may result in harmful medication responses, a

patient's condition getting worse, or in extreme situations, even death. (Health Canada,

2011)

 Increase healthcare cost: it is clear that medication error lead to the increase healthcare

cost because of additional treatment cost, prolonged hospital stay and higher medical

expenses. (Health Canada, 2011)

 Civil action: If a medication error happens, the patient or the patient's family may file a

legal lawsuit or charge fine against the healthcare provider. In a rare medication error

case in point in Canada, a doctor requested novocaine as to be injected into a patient's

thumb, but the nurse gave him adrenaline instead, which resulted in a deadly mistake.

The nurse had inquired about the medication from a different nurse in another area, and

she received a vial, which she took to the doctor to be injected. The doctor and the nurses

had not checked the bottle's label. Both nurses were therefore judged to have been
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careless. The doctor was found not to have been negligent by the court because he had

good reason to trust the nurses' ability to read the label. (CNPS, nd)

 Damage to reputation: If any error occur I hospital during treatment it directly affect the

reputation of the provider which has been build in many years.

Likelihood Consequences:

Studies have shown that the likelihood of serious consequences from medication errors in

Canada is relatively high. Medication errors affect an estimated 1 in 9 patients in Canadian

hospitals. The likelihood of a medication error occurring during a hospital stay in Canada is

estimated to be around 7-10%.Certain high-risk medications and vulnerable patient

populations, such as the elderly, have an even higher risk of medication errors. (Medical

Malpractice, 2020)

Risk Management Strategy:

 Pay close attention to all aspects of medication administration (CNPS, nd)

 Use a calculator or develop professional computational skills, and when required by

policy, have another healthcare provider independently verify the information they

provided.(CNPS, nd)

 When storing medications in the refrigerator or other safe, separate spaces, keep

neuromuscular blocking substances apart from all other drugs in the pharmacy to

prevent medication error.( ISMP, 2023)

 All storage containers (refrigerated and non-refrigerated) and/or ADC pockets and

drawers containing neuromuscular blocking agents should have supplementary labels

attached. (ISMP, 2023)

 Medication Errors Resulting from Inaccurate Patient Medication Lists (ISMP, 2023)
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Serious Consequences: Significant medication dispensing errors, such as failing to identify

drug interactions, delivering the incorrect medicine or dose, or using the incorrect dosage

form, can result from incomplete patient prescription lists. These mistakes may have

detrimental effects on the health of the patient, such as medicine side effects, deterioration

of the patient's condition, or even death. (CNPS, nd)

Relatively High Likelihood: One of the main causes of medication errors is inaccurate

drug lists, particularly when there is a change in care such as a hospital admission or

discharge. These errors may be caused by a number of things, including incomplete

electronic health records, inadequate patient communication, and a lack of collaboration

between healthcare professionals.(Who, nd)

Given the serious potential consequences and relatively high likelihood of medication

errors stemming from inaccurate patient medication lists, simply "accepting" this risk would

not be an appropriate or responsible strategy. Instead, I would recommend the "Reduce

Likelihood and Impact" strategy, which involves implementing a range of evidence-based

interventions to improve the accuracy and completeness of patient medication information,

such as:

 Effective processes for balancing medications during changes in care(Gutiérrez et ai,

2023)
 Improved medication knowledge and involvement of patients(Gutiérrez et ai, 2023)
 Staff members must receive clear policies, procedures, and medication management
training. (Gutiérrez et ai, 2023)
By actively addressing the root cause of medication error the organization can reduce the
consequences of medication error.
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Reference
Health Canada's role in the Management and Prevention of Harmful Medication Incidents. (2011, June
20). Retrieved from Health Canada: https://www.canada.ca/en/health-canada/services/drugs-health-
products/medeffect-canada/medeffect-canada-role-management-prevention-harmful-medication-
incidents.html

Implement strategies to prevent persistent medication errors and hazards. (2023, March 23). Retrieved
from ISMP: https://www.ismp.org/resources/implement-strategies-prevent-persistent-medication-
errors-and-hazards

InfoLAW: Medication Errors. (n.d.). Retrieved from Canadian Nurses Protective Society :
https://cnps.ca/article/medication-errors/

Medication error. (n.d.). Retrieved from European Medicines Agency:

https://www.ema.europa.eu/en/human-regulatory-overview/post-authorisation/pharmacovigilance-
post-authorisation/medication-errors

Medication Errors are Among the Most Common Medical Mistakes in Canada. (2020, Auguest 27).
Retrieved from Neinstein: https://medicalmalpractice.ca/news-blog/medication-errors/medication-
errors-medical-malpractice-lawyers

Medication Without Harm. (n.d.). Retrieved from WHO: https://www.who.int/initiatives/medication-

without-harm

Ciudad-Gutiérrez, P., Del Valle-Moreno, P., Lora-Escobar, S. J., Guisado-Gil, A. B., & Alfaro-Lara, E. R. (2023).
Electronic Medication Reconciliation Tools Aimed at Healthcare Professionals to Support Medication
Reconciliation: a Systematic Review. Journal of medical systems, 48(1), 2. https://doi.org/10.1007/s10916-023-
02008-0
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