Prevent Medication Errors Adverse Patient

¶ … Prevent Medication Errors

Adverse patient incidents can assume a wide variety of events, including falls with injury, fires involving patients, and even patient abuse, but one of the most common and preventable incidents is medication errors. Because the clinical outcomes involving medication errors can be life-threatening, the subject has been the focus of an increasing amount of attention in recent years and clinicians in both tertiary healthcare facilities as well as outpatient settings have identified a number of methods that can be effective in reducing the number of medication errors. To determine the prevalence and type of medication errors being reported across the country and what healthcare providers are doing about the problem, this paper provides a review of the relevant peer-reviewed literature followed by a summary of the research and important findings in the conclusion.

Review and Discussion

Among the various quality assurance measures typically in place in many healthcare settings and one of the key measures of patient safety is the prevalence of medication errors (Anson, 2000). One of the problems associated with identifying and comparing precise levels of medication errors in various healthcare settings across the country, though, is a lack of operationalization of what constitutes a medication error. In this regard, Meadows (2003), a consultant with the U.S. Food and Drug Administration (FDA), reports that, "Since 1992, the Food and Drug Administration has received about 20,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no 'typical' medication error, and health professionals, patients, and their families are all involved" (p. 20). Indeed, author Gordon and physician McCall (1999), emphasize that, "When patients act as their own nurse or doctor, they often make mistakes and may die as a result. And when family members are required to fill in for professional nurses there are similar hazards" (p. 11).

Based on its analysis of fatal mediation errors reported during the period from 1993 to 1998, the FDA determined that the most common types of errors involved administering an improper dose (41%), providing the incorrect medication (16%), and the use of the incorrect path for administration (16%) (Meadows, 2003). The most commonly cited causes for the medication errors reviewed by the FDA were performance and knowledge deficits account for almost half of all medication errors (44%) as well as simple communication errors (16%) (Meadows, 2003). In addition, nearly 50% of the fatal medication errors involved patients over the age of 60 years, and Meadows emphasizes that the elderly are at particular risk for medication errors because of the large number of different medications they are typically prescribed (Meadows, 2003).

Likewise, young people also represent a high-risk segment of the population since medications are frequently dosed based on their weight, and accurate calculations are absolutely essential (Meadows, 2003). This point is also made by registered nurses Stratton, Blegen, Pepper and Vaughn (2004), "Medication administration errors can threaten patient outcomes and are a dimension of patient safety directly linked to nursing care. Children are particularly vulnerable to medication errors because of their unique physiology and developmental needs" (p. 385). In fact, the majority of adverse drug reaction deaths in the nation's hospitals involve tend to be related to incorrect dosages, and these types of medication errors may represent a leading cause of hospital death in the United States (Daughton, 2003). According to Daughton, a researcher at the U.S. Environmental Protection Agency, "Indeed, deaths from medication errors occurring both in and out of hospitals exceed 7,000 annually in the United States -- exceeding those from workplace injuries" (2003, p. 757).

Tertiary healthcare facilities and other healthcare providers have identified some effective methods for reducing the number of medication errors through the use of technology, improving processes, targeting those types of specific medication errors that result in harm to patients, and promoting an organizational culture of safety (Meadows, 2003). One approach that has been shown to be particularly effective has been the use of bar codes and scanners together with computerized patient information systems; in these settings, bar code technology can help to prevent a number of different types of medication errors, including administering the wrong drug or dose, or administering a drug to a patient with a known allergy (Meadows, 2003). In fact, the nation's largest healthcare provider, the Department of Veterans Affairs (VA), has implemented the use of bar codes at all of its 152 medical centers and the impact has been an impressive reduction in the number of medication errors. According to Meadows, "For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86% over a nine-year period" (2003, p. 21).