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). ...
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 ...
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The technicality, complexity and the chaotic working atmosphere of nurses make nurses more amenable to medication errors. Nurses are taught that administration of medication is an individual responsibility and that the blame for administering wrong medication is on the individual who has administered the drug.
There are 5 medical administration rights; the right patient, the right dosage, the right drug, the right time, and the right route. As noted by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), medication error is any preventable occurrence or event that may lead to or cause patient harm or inappropriate medication use, while the medication is under the control of a health care provider, consumer, or patient.
Medication errors are also errors which are made but corrected before actually reaching the patient. Studies suggest a number of factors which promote positive nursing environments and reduce adverse patients events such as medication errors. Studies also suggest a link between nursing staffing levels and the frequency of intercepted medication errors (Sleinitz, Heyde, & Kloft, 2012).
In this practice, the safety committee and the quality manager (QM) of any healthcare institution focus on becoming a source of medical safety or error reduction expertise.
An example of patient practice that relates to
This essay discusses the problem of medical errors on a specific example from the author's life. The author tells what actually happened and what he had to do. He also describes the conclusions that he made from this situation.
s medication error as any wrongful or incorrect administration of medication, such as failure to administer or prescribe the appropriate drug, failure to observe the appropriate time of administrating medication, lack or inadequate awareness of adverse effects of particular drug
ed as intended or the use of a wrong plan to achieve an aim.” The causes of medical errors have been categorized into two broad areas which include active failure and latent conditions. What comes to mind most often is active failure when an error is mentioned due to the
It is not probable to intercept most administration errors. However, with the recent advancements being witnessed in electronic medication, it is now possible to minimize medication errors during the administration
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