Lesson 7 Small Group Discussion

This article define medication errors and when occur these medication administration errors (MAEs) such as one or more of the seven rights of medication administration (right patient, right drug, right dose, right time, right route, right reason and right documentation) are violated. Moreover, the writers suggest study more about nurses’ knowledges with and perceptions on preventing MAEs through this journal. Wulff, K., Cummings, G. G., Marck, P., & Yurtseven, O. (2011). Medication administration technologies and patient safety: a mixed-method systematic review. Journal of Advanced Nursing, 67(10), 2080-2095.

The studies reviewed are: Medication errors: classification of seriousness, type, and of medications involved in the reports from a University Teaching Hospital (Dalmolin, Rotta, & Goldim, 2013), Types and causes of medication errors from nurse 's viewpoint (Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013), and Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence (Keers, Williams, Cooke, & Ashcroft, 2013). The remaining data reviewed consisted of peer reviewed articles, they were the following: The Effect of a Safe Zone on Nurse Interruptions, Distractions, and Medication Administration Errors (Yoder, Schadewald, & Dietrich, 2015), Celebrating Human Resilience to Provide Safe Care (Moffett & Moore, 2011), and A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses ' Roles in Practice (Sherwood & Zomorodi,

Medication errors is any correctable event that could lead to inappropriate

Medication errors can be very dangerous for the ones taking the wrong medicines or doses; therefore, safety measures must be in place. Administering them must be done with an understanding and focus. One missed check could have a staff member giving a resident the wrong set of pills. Some interventions to help prevent the medication error from occurring is to first report errors. When errors are reported, the main cause is to try and never let the error occur again.

Medication Errors in Healthcare The nursing profession entails many responsibilities that range from providing emotional support to administering medications that could result in death for those receiving care. Approximately 40% of a nurse's day consists of passing medication, a duty that sets their level of liability above many other healthcare professions (McCuistion, Vuljoin-DiMaggio, Winton, Yeager, & Kee, 2018). Despite today's advances in technology and nursing education, the frequency of medication errors is still staggering. To ensure that the benefits of nursing outweigh the risks, nurses look to the Quality and Safety Education for Nurses (QSEN) six core competencies for guidance.

Also, it can cost a patient’s life and the hospital thousands of dollars. Therefore, all medication errors must be reported following the appropriate protocol to prevent serious adverse events.” Although there are some consequences to each medication error, it is imperative to report it in order to improve patient care and safety. Medication errors can significantly affect patient safety (Elden & Ismail 2016). Medication errors do not only occur during the administration stage, they can occur from the ordering and down to the provision stage (Radley,

ADEs associated with medication discrepancies can prolong hospital stays and, in the post-discharge period, may lead to emergency room visits, hospital readmissions, and utilization of other health care resources. Preventable adverse drug events (PADE) are associated with 1 of 5 injuries or deaths and a result of poorly designed systems, which often lack independent redundancies. Preventable ADEs at transition points of care account for 46-56% of all medication errors. One strategy to reduce PADEs and ADEs is to reconcile the medication orders between the two transition points. The Institute for Healthcare Improvement (IHI) defines medication reconciliation as a formal process to compile a list of all the medications a patient is taking before admission, and comparing it with the doctor’s admission, transfer and discharge orders.

Preventable medical mistakes cause approximately 200,000 deaths around the United States each year. (1) More than 1,000,000 Americans are negatively impacted by medication errors each year caused by inadvertent mistakes in the prescription filling process. With 4 out of 5 adults taking at least 1 medication daily and 1 out of 4 adults taking 5 or more medications daily nationwide, errors like these cost healthcare industry billions of dollars per year. Health information technology were developed to transform healthcare services, the way they are provided and compensated. Electronic prescribing (e-prescribing) becomes an internal part of that transformation process, which can be confirmed from annual Surescripts’ National Progress Report.

This resulted in 7% of the respondents reporting involvement in a medication error during that past year. Good interpersonal skills and effective communication ensures that concerns regarding patient safety can be brought up without seemingly challenging the knowledge of the other healthcare

With increasing the acceptance of using e-prescribing in health care , evaluating and understanding the types of e-prescribing errors can help to identify the prober ways to prevent future e-prescription errors from reaching patients. It is also important to use health information technology to improve safety, such as use of technology to identify and monitor patient safety events, risks and hazards ;and to intervene before actual harm occurs

Our solution to medication errors is here, it is just a matter of implementing it into our

Medication use is potentially dangerous. Polypharmacy is increasing, and makes it harder to keep track of side effects and interactions and of potentially inappropriate drug combinations. “The risk of serious consequences, hospitalization, and death due to medication errors increases with patients’ age and number of medications (Scand J Prim Health Care, 2012)”. For example, the GP is supposed to monitor the patient's regular medication, but does not always do so. Lack of monitoring and keeping track of patients’ medication use is a main cause when a patient is given inappropriate drugs.

Barriers to the reporting of medication administration errors and near misses: an interview

One significant barrier is the potential detrimental impact on physician and staff workflow. Computer-based systems that allow clinicians to prescribe drugs electronically are designed to automatically warn of potential medication errors, but a new study reveals clinicians often override the alerts and rely instead on their own judgment. A study, at Dana-Farber Cancer Institute showed that most clinicians find the current medication alerts a task of annoyance rather than a valuable tool for patient safety. Although the e-prescribing alert with improve medication safety, we the society will not see its benefit until there is a system to help clinicians better manage medication safety alerts. This study shed a light on the real value of e-prescribing alerts in the eyes of our clinicians.

Accountability for delivery of patient safety improvement targets with relation to medication errors. Janine was an enthusiastic and engaging speaker, and her passion for reducing medication error and the involvement of her junior doctors was evident. She spoke about the Juniors’ Educational Drug Initiative (JEDI) and discussed the ‘carrot and stick’ as a simple model to describe motivation.