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Fixing the System to Fix Errors: Causes of and Solutions to Medication Errors Name University June 26, 2013 Abstract This paper examined 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.
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). ...
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