Factors, Causes, and Prevention of Medication Errors Literature Review Essay

Factors, Causes, and Prevention of Medication Errors Literature Review Essay

A thorough search was done in ScienceDirect, BioMedCentral, and PubMed databases to find the relevant sources for the material supplied. The first step was constructing particular search queries about medication errors, their causes, and ways to avoid them. The following keywords were used in these searches: “medication errors,” “communication breakdowns,” “look-alike medications,” “complex medication regimens,” “human factors,” “medication safety culture,” “technology in medication safety,” “patient involvement,” and “medication reconciliation.” The databases were thoroughly searched using these keywords, taking into account only publications released during the last 5 years. The most relevant and recent papers that offered empirical evidence, theoretical frameworks, or recommendations relating to the topic after evaluating the titles and abstracts of the retrieved articles were selected.

Literature Review

Communication breakdowns among healthcare personnel and insufficient education and training on medication have been cited as factors contributing to prescription errors (Tiwary et al., 2019). Miscommunication or a lack of communication among healthcare personnel can result in mistakes during drug prescribing, dispensing, and administration. An inadequate understanding of drug interactions, dosing standards, and medication administration practices can also raise the likelihood of errors. To avoid these errors, healthcare organizations should encourage effective interdisciplinary communication, employ standardized communication methods, and provide extensive training and education for healthcare personnel.

Look-alike and sound-alike drugs (LASA) pose a significant risk to medication safety (Gangakhedkar et al., 2019). Medications with identical names or packaging can lead to misunderstanding and inadvertent replacement, while complex prescription regimens increase the risk of reconciliation, dosing, and timing errors (Gangakhedkar et al., 2019). To deal with these factors, medical facilities use strategies such as distinct labeling to distinguish LASA medications, automated alerts, support systems for electronic health record decisions to flag possible mistakes, and drug regimen simplification to improve adherence (Zafar & Liaqut, 2020). These precautions are critical in decreasing hazards, enhancing patient safety, and reducing medication errors related to look-alike and sound-alike drugs and complex therapies.

Human variables such as weariness, stress, and workload play a part in drug errors, making exhausted healthcare practitioners more likely to make mistakes (Tsegaye et al., 2020). The rigorous nature of healthcare jobs, long shifts, and minimal breaks can impair attention to detail and increase the likelihood of errors. Adequate staffing levels, particularly proper nurse-to-patient ratios, are critical in reducing fatigue-related errors and providing essential support to healthcare providers (Tsegaye et al., 2020). Furthermore, incorporating breaks and rest intervals during shifts can reduce fatigue and improve cognitive functioning (Montgomery et al., 2020). Work-hour restrictions, such as enacting regulations that limit consecutive working hours and guaranteeing adequate time off between shifts, are critical measures for addressing workload-related variables and promoting alertness and performance (Montgomery et al., 2020). Healthcare organizations can reduce the chance of medication errors and improve patient safety by addressing the well-being of healthcare personnel and implementing techniques to manage exhaustion, stress, and workload.

The lack of a structured pharmaceutical safety culture inside healthcare organizations will likely lead to medication errors (Machen et al., 2019). A safety-first culture encourages reporting and learning from mistakes, fosters teamwork, and promotes open communication. Setting up reporting systems, offering feedback and education, and developing a non-punitive environment are all essential steps in enabling a pharmaceutical safety culture.

Technology can help avoid drug errors (Hutton et al., 2021). CPOE systems, scanning bar codes, and automated systems for dispensing improve accuracy and reduce errors in medicine prescribing, administration, and dispensing. These tools aid decision-making, identify potential drug interactions, and reduce manual errors. Investing in and adopting technology solutions can increase pharmaceutical safety significantly.

Patient involvement and empowerment and medication reconciliation protocols during care transitions are critical in reducing medication errors (Patel et al., 2019). Drug safety can be improved by proactively engaging patients in their care by providing complete drug histories, addressing questions, and reporting concerns or adverse effects. Furthermore, doing complete medication reconciliation during transitions of care aids in identifying and resolving differences, minimizing errors, and enhancing patient safety.

Healthcare facilities can work to avoid medication errors and improve patient safety by addressing issues like communication breakdowns, insufficient knowledge, look-alike medications, complex medication regimens, human factors, organization culture, science and technology, patient engagement, and medication reconciliation.



Gangakhedkar, G. R., Waghalkar, P. V., Shetty, A. N., & Dalvi, A. M. (2019). Look-alike drugs: Avoiding potential medical errors. International Journal of Preventive Medicine, 10(1), 9. https://doi.org/10.4103/2008-7802.250291

Hutton, K., Ding, Q., & Wellman, G. (2021). The effects of bar-coding technology on medication errors. Journal of Patient Safety, 17(3), 1. https://doi.org/10.1097/pts.0000000000000366

Machen, S., Jani, Y., Turner, S., Marshall, M., & Fulop, N. J. (2019). The role of organizational and professional cultures in medication safety: A scoping review of the literature. International Journal for Quality In Health Care: Journal of the International Society for Quality in Health Care31(10), G146–G157. https://doi.org/10.1093/intqhc/mzz111

Montgomery, A. P., Azuero, A., Baernholdt, M., Loan, L. A., Miltner, R. S., Qu, H., Raju, D., & Patrician, P. A. (2020). Nurse burnout predicts self-reported medication administration errors in acute care hospitals. Journal for Healthcare Quality, 43(1). https://doi.org/10.1097/jhq.0000000000000274

Patel, E., Pevnick, J. M., & Kennelty, K. A. (2019). Pharmacists and medication reconciliation: a review of recent literature. Integrated Pharmacy Research and Practice, Volume 8, 39–45. https://doi.org/10.2147/iprp.s169727

Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by health care professionals may lead to life-threatening complications: Examples from two case reports. Wellcome Open Research, 4(1). https://doi.org/10.12688/wellcomeopenres.15042.1

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, Volume 13(13), 1621–1632. https://doi.org/10.2147/ijgm.s289452

Zafar, R., & Liaqut, M. (2020). Assessment of look-alike, sound-alike, and read-alike (LASARA) medicine – errors in pharmacy. Journal of the College of Physicians and Surgeons Pakistan, 30(4), 425–428. https://doi.org/10.29271/jcpsp.2020.04.425

Locate a research article with a literature review on a healthcare topic that has been published within the last five years utilizing the library sources provided by Aspen University. After reading the article, report on its findings. How many articles were reviewed? What was the focus of the review? What were the findings? Be sure to cite your sources.

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