Causes of and Solutions to Medication Errors - Essay Example

? Fixing the System to Fix Errors: Causes of and Solutions to Medication Errors June 26, This paper examined the causesof and solutions to medication errors. Human, environmental, and organizational factors cause medication mistakes, but a number of important environmental and system-based changes can be made to decrease the risks and instances of medication errors. The specific causes of medication errors are: active failures, error-provoking conditions, and latent circumstances. The solutions provided respond to problems that occur at individual, team, and organizational levels. These solutions aim for immediate and long-term changes in how healthcare professionals see and execute the medication process. Quality management philosophies and systems are highlighted because they emphasize a learning organization culture that critically determines and resolves medication errors in the long run. Hence, medication errors are not the responsibility of prescribers alone, but a responsibility of the healthcare team and the healthcare organization, as well as the government. Introduction On September 14, 2010, 50-year-old Kimberly Hiatt, a longtime critical care nurse at Seattle Children’s Hospital, administered the wrong dosage of calcium to a fragile baby, Kaia Zautner (Aleccia, 2011). Zautner died five days later, although it was not clear whether the medication error killed her. Nevertheless, Hiatt, who was fired and underwent a state nursing commission investigation, committed suicide seven months after Zautner died. Aleccia (2011) reported that around 1 in 7 Medicare patients are harmed because of medication errors. Andel et al. (2012) estimated the economic costs of medication errors using quality-adjusted life years (QALYs) and the Institute of Medicine’s report of 98,000 deaths every year. They discovered that the conservative cost of these deaths is “$73.5 billion to $98 billion in QALYs” (Andel et al., 2012, p.41). Because of the morbidity and mortality effects of medication errors, it will benefit the healthcare system and society, if they can determine the causes of and solutions to medication errors. Human, environmental, and organizational factors cause medication mistakes, but a number of important environmental and system-based changes can be made to decrease the risks and instances of medication errors. Causes of Medication Errors: Providers and Environment Tully et al. (2009) examined the causes of and factors connected to medication errors that concern prescriptions for hospital inpatients. They grouped the causes according to Reason’s model of accident causation, which will also be used in this essay: active failures, error-provoking conditions and latent conditions. Active Failures Active failures pertain to hazardous acts that prescribers make, which means that all medication errors consist of at least one active failure (Tully et al., 2009, p.826). One of the most common sources of active failure is knowledge-based. Prescribers committed mistakes either because they did not know enough about the drug or about the patient (Grissinger & Kelly, 2005, p.62; Tully et al., 2009, p.826). Some of the examples are giving the wrong dose or not being aware that a patient’s co-morbidity was a contraindication for the provided medicine. Another kind of active failure is skill-based or based on memory lapses (Tully et al., 2009, p.826). A couple of instances are interruption of the prescriber, who then makes a mistake, and when prescribers were too busy that they made an error. Aside from skill-based faults, policy violations are also problematic. Violations refer to active choices wherein prescribers ignore formal or informal policies that they were expected to follow (Tully et al., 2009, p.826). One example is medication error that comes from a medical student because his supervisor did not check his prescription. These active failures contribute to numerous medication errors. Error-provoking Conditions Error-provoking conditions are different from active failures because they are more environment-based and task-oriented (Tully et al., 2009, p.828). These conditions do not always directly cause errors, but they are risk factors that can make active failures more prevalent. These conditions can be classified according to the following: the prescriber, the immediate workplace, the healthcare team, the prescribing responsibility, and the patient (Tully et al., 2009, p.828). Lack of sufficient knowledge regarding particular drugs have commonly causes prescriber-centered problems. For instance, junior doctors have made more medication errors than senior ones, according some studies (Tully et al., 2009, p.828). Many errors were made during experiences of being hurried and having heavy workload, such as working for more than 12 hours straight because of shortage in providers (Tully et al., 2009, p.829). Fatigue and sleep deprivation can cause mental lapses that can result to medication errors. The working environment contributes to medication errors when the hospital is understaffed and lacks access to records and computers. Absence of access to a computer can be connected to medication errors because prescribers cannot check drug and/or patient information (Tully et al., 2009, p.830). Sauberan et al. (2010) studied five cases of neonatal medication-error cases. These medication errors transpired because several kinds of medicine looked alike or sounded alike. They learned that these errors underscored problems in the hospital’s system, especially in neonatal medication storage, labeling, delivery, knowledge, and administration documentation. Workplace systems, policies, and practices can cause medication errors. Healthcare team problems arise because of poor communication within the team, ambiguities in responsibilities, and poor documentation (Tully et al., 2009, p.830). Regarding the prescribing task errors, some factors are “non-routine and non-standardized prescribing tasks” (Grissinger & Kelly, 2005, p.65;Tully et al., 2009, p.830). The route of administration can also cause problems, such as through eye drops and inhalation (Tully et al., 2009, p.831). Moreover, the patient can also be the cause of medication error, if their diseases have progressed enough that they could no longer communicative effectively or when there are language barriers (Tully et al., 2009, p.831). Other conditions that have been studied as risk factors are: increasing age for children and adult, children in intensive care, and adults in medical and surgical wards (Tully et al., 2009, p.831). Latent Conditions Latent conditions are organization-based errors that increase the risks for error-provoking conditions and active failures (Tully et al., 2009, p.831). Some examples are reluctance in questioning senior providers and poor conflict resolution in the organization. At times, doctors might see prescription as not a critical task too (Tully et al., 2009, p.831). Other potential problems are lack of integrated clinical and pharmacy information systems, problematic work shifts, and extension of work hours for junior doctors (Tully et al., 2009, p.831). These latent conditions can promote an environment that is conducive to and does not question or report medication errors. Solutions to Medication Errors: Environment to Help Providers Solutions to Active Failures Prescribers must be duly trained for their roles and responsibilities, and they must also have access to a computer and other reference materials, so that they can easily check the characteristics of drugs and patients (Sauberan et al., 2010, p.55). Grissinger and Kelly (2005) studied medication errors that involve women. They noted medication errors that came from verbally expressed medication. They suggested that if verbal communication cannot be avoided, the following steps must also be done: authorized personnel must only be the ones allowed to take verbal instructions; medication orders must be transcribed and read back to prescriber; verbal orders must be recorded directly to patient sheets or prescription pads as soon as possible; and prescribers must be completely aware of patient characteristics and needs (Grissinger & Kelly, 2005, p.64). These solutions pertain to policies and practices that respond to knowledge and skills limitation of prescribers and concerned staff. Solutions to Error-provoking Conditions Even if medication errors are caused by lack of knowledge or physical exhaustion and stress, this essay asserts that the system can be made to be as error-proof as possible. The system can be changed to focus on ensuring that mix-ups in names and appearances are avoided through premade or prepared solutions for suitable target patients and providing non-confusing names and color labels. Sauberan et al. (2010) recommended the following steps that can hospitals can apply in their systems appropriately: [I]npatient pharmacy system had already adopted many recommended strategies for preventing medication errors in our neonatal patients, including limiting the number of medication concentrations and strengths available, using standard concentrations for continuous medication infusions, using commercially available pediatric specific formulations whenever possible, dispensing all medications in patient-specific unit dose i.v. and oral syringes, and implementing 24-hour pharmacy oversight of medication ordering, verification, and dispensing. (p.55). Neonatal, pediatric, and adult medication should be separated in different storage sites. These recommendations ensure the right dosage for patients through better storage and labeling, so that errors can be avoided despite human lapses. Solutions to Latent Conditions Latent conditions can be more directly addressed through organizational changes that change inert organizations to learning organizations with continuous learning cultures. These changes include the promotion of conflict resolution models involving medication and the establishment of open communication channels. Andel et al. (2012) emphasized the need for designing hospitals around high-quality care using quality improvement philosophy, systems, and policies. They promoted the use of Six Sigma and Lean management methods and systems that will overhaul how healthcare providers see and execute medication responsibilities (Andel et al., 2012, p.44). Moreover, Andel et al. (2012) recommended changing the incentives and punishment for the healthcare system. They noted that hospitals get paid before whether they provided quality care or not, and even when their staff made medical errors. In other words, hospitals know that there is no incentive to promoting quality measures. The recent efforts of the government to monitor quality care for Medicaid recipients and to punish those who do not provide quality care are lauded. Andel et al. (2012) stressed the necessity for higher incentives that will push providers to improve healthcare provision, such as tying performance to their compensation (p.45). The emphasis is on designing organizations to be learning units, where the culture of learning and collaboration is central to resolving medication errors in the long run. Conclusion Medication errors cannot be entirely avoided because of the human element in it. Nevertheless, workplace systems can be changed to ensure fewer medication errors. A system where prescription processes are standardized and doses are prepackaged and clearly labeled and properly color-coded is important. Personnel must be duly trained to provide the right medication, while staff must be encouraged to check and question dubious medication. Finally, the entire organization must pursue constant quality management efforts, which will address medication errors in a sustained manner. References Aleccia, J. (2011, June 27). Nurse's suicide highlights twin tragedies of medical errors. NBC News.com. Retrieved from http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.Ucr3cDvItSY Andel, C., Davidow, S.L., Hollander, M., & Moreno, D.A. (2012). The economics of health care quality and medical errors. Journal of Health Care Finance, 39(1), 39-50. Grissinger, M.C., & Kelly, K. (2005). Reducing the risk of medication errors in women. Journal of Women's Health, 14(1), 61-67. Sauberan, J.B., Dean, L.M., Fiedelak, J., & Abraham, J.A. (2010). Origins of and solutions for neonatal medication-dispensing errors. American Journal of Health-System Pharmacy, 67(1), 49-57. Tully, M.P., Ashcroft, D.M., Dornan, T., Lewis, P.J., Taylor, D., & Wass, V. (2009). The causes of and factors associated with prescribing errors in hospital inpatients. Drug Safety, 32(10), 819-836. Read More