Medication Errors

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Medication Errors: A Literature Review
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Pharmacology 2
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September 17 2008

The American Society of Hospital Pharmacists define a medication error as “episodes of drug misadventure that should be preventable through effective systems controls involving pharmacists, physicians and other prescribers, nurses, risk management personnel, legal counsel, administrators, patients and others in the organizational setting, as well as regulatory agencies and the pharmaceutical industry” (Armitage, G., & Knapman, H. 2003 ).This paper shall discuss the various causes of, and methods for the prevention of medical errors. In looking at this important and complex topic it is hoped that healthcare providers will be made aware of situations and conditions that have the potential to lead to medication errors. With an expanded knowledge of this the healthcare provider will be better equipped to prevent a medication error from occurring. A reduction of medication errors is highly desirable so that the patient’s quality of care is at the highest level, and any adverse effects due to medication are minimized to the fullest extent.

In the first article reviewed, Adverse events in drug administration, the topic discussed is the causes of medication errors. The article first defines a medication error and then discusses problems with establishing an accurate count of medication errors “the issue of under reporting ... is due to either a lack of appreciation that an error has occurred; the error is not considered serious enough to report; or ... there is a reluctance to report” (Armitage, G., & Knapman, H. 2003). Many of the situations environments, and conditions that facilitate the occurrence of medication errors are discussed in the remainder of the paper.

The second paper reviewed, Nature of preventable adverse drug events in hospitals, firstly deals with the frequency of medication errors “The reported median frequency of preventable adverse drug effects was 1.8%” ( Kanjanarat, P., Winterstein, A. G., Johns, T. E., Hatton, R. C., Gonzalez-Rothi, R., & Segal, R. 2003). It then discusses the drugs most commonly associated with medication errors. Types of errors, that is which of the five rights was violated, is then examined. Finally the type of adverse outcome, and major body system affected by the error is discussed..

The third paper reviewed, To Err is Human, To Share is Devine, mainly deals with the importance of the reporting of both medication errors and near misses. “Practitioner reporting and sharing of incident information internally and externally can enhance patient safety by helping to prevent recurrence of similar events”.(Koczmara, C., Dueck, C., & Jelincic, V., 2006). Several specific examples of medication errors and near misses are given along with the resulting changes made to the aspect of the system that was the main contributing factor in the incident.

In the fourth paper reviewed, Heparin Error Highlights Risk and Need for Health Care Risk Managers to Take Action, a single medication error is looked at in detail. This incident involved a dosage mistake with heparin. “...containing 10,000 units per milliliter of heparin instead of the common dosage of 10 units per milliliter. The report found that the children actually received two of the vials.” (Heparin Error Highlights Risk and Need for Health Care Risk Managers to Take Action, 2008 ). The root cause of this medication error was found to be product labeling as both the lower and higher dose drugs had very similar labeling. Media attention resulting from this medication error led to the drug manufacturer to change product labels. Several suggestions are then presented on ways for hospitals to change systems and procedures in order to prevent a recurrence of such an error.

Overall any medication error has a negative impact on client care. While a medication administered at the wrong time has little...
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