Factors and Causes of Medication Errors Literature Review Essay

Prominent databases such as ScienceDirect, PubMed and BioMedCentral were used to identify medical journals that delve into the factors and causes of medication errors. The parameters used in the search of the articles were designed to identify the sources published in the last five years, and they encompassed a wide range of keywords and subject headings. The search focused on articles that explored medication errors in the healthcare sector and that emphasized the underlying causes and the contributing factors. The strategy used in the search entailed the utilization of keywords, Boolean operators, truncation and Medical Subject Headings (MeSH) terms. The inclusion criteria were studies that focused on human subjects, written in English and published in peer-reviewed journals. Articles that had a strong empirical emphasis, including qualitative and quantitative studies, meta-analyses and systematic reviews, were prioritized for the literature review.

Literature Review

A review by Alrabadi et al. (2021) aimed to analyze the causes of medication errors that affect patient safety negatively. The leading cause of medication errors identified is the distraction and interruptions that are faced by nurses in the different phases of administration of medication. Physicians, patients, assistive personnel and co-workers often distract nurses when they are administering medications, often leading to errors. The authors established that nurses face up to 10 interruptions each hour, often leading to a high number of near misses and commission of medication errors. Additionally, illegible handwriting during prescription and updating of patient files has been a persistent factor that has contributed to the commissioning of medication errors. Healthcare workers involved in the administration and dispensation of medications can be affected by this poor penmanship leading them to misinterpret the details of the medications, resulting in incorrect dosages or administration of wrong medications to patients (Alrabadi et al., 2021).

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Studies by Faraj Al-Ahmadi et al. (2020) explored the different factors contributing to medication errors, such as emotional stress, fatigue, burnout, compliance with policies and organizational support. The subjects of the study indicated that they suffered burnout, emotional exhaustion and disengagement from work. Emotional stress, implicated in medication errors, is seen as a multifactorial issue by the authors that often arise from different factors such as lack of organizational support, a heavy workload and poor compliance with policies (Faraj Al-Ahmadi et al., 2020). The pharmacy staff reported that they suffered from moderate levels of fatigue, which required that they take short breaks and that alertness strategies should be implemented to help them to prevent any fatal errors. The authors concluded that even though moderate fatigue may be perceived as controllable, it is a potential contributor to medication errors. Dissatisfaction of the workers with the regulations at work, ineffective communication and poor compliance with policies were identified as the significant causes of medication errors (Faraj Al-Ahmadi et al., 2020). The study recommends that organizations should implement a supportive culture that fosters effective communication and that considers the wellbeing of the workers.

Schroers et al. (2020) literature review examines the causes of medication errors based on findings from different studies. The authors concluded that knowledge-based factors were the main causes of medication errors. Under these factors, difficulties in using technology, interpretation of standard protocols and guidelines and calculation of the dosages of medication were the root causes of medication errors. It also established that inexperienced nurses, and those who lacked training and clinical experience were likely to commit errors during medication. Some other contextual factors implicated in the lack of knowledge include the lack of adequate supervision and support for novice nurses. The personal factors associated with medication errors include a lack of confidence in seeking clarification of orders, making assumptions, stress, negligence and complacency (Schroers et al., 2020). Complacency, especially regarding a second check of medications, was prevalent in most nurses. Additionally, physical exhaustion and fatigue of the workers were significant causes of medication errors, usually resulting from heavy workloads and understaffing.

A study by Mulac et al. (2021) aimed to identify the risk factors that are associated with numeracy errors in the processes of medication and to propose the measures that should be implemented to improve the safety of the patients. The authors stressed the need for resilience in medication management systems to prevent medication errors and the role of individual and organizational factors in the commission of medication errors. One main area identified that needed attention was the preparation of intravenous medications, which was implicated in most cases of medication errors. Most nurses deviated from procedures such as dose calculations and dilution. The implementation of standard IV drug concentrations and prefilled syringes were proposed to help reduce medication errors. The incorrect use of infusion pumps is also a common cause of medication errors due to incorrect programming (Mulac et al., 2021). The authors suggested that the adoption of smart infusion pumps, which can be connected to Electronic Health Records, could help to prevent some of these errors as they promote integrity and decreases the chances of healthcare workers committing medication errors.

There are different infusion pump errors that have been associated with medication errors, such as medication selection errors, mechanical malfunctions, programming and administration errors. Some of the factors that can lead to infusion pump errors are inadequate training, malfunctions of the systems, human errors and limitations in technology (Kirkendall et al., 2020). The commonest error identified is the programming errors, in which the healthcare workers input incorrect infusion rates or medication dosages. The majority of these errors arise from distractions or confusion when programming, complex calculation of dosages, or unfamiliarity with the interface of the devices (Kirkendall et al., 2020). These errors are likely to lead to under or overdosing, which can affect the efficacy of the drugs or compromise the safety of the patients. These errors can also entail the administration of wrong medications and incorrect infusion rates, putting the patient at risk of adverse drug reactions or inadequate therapeutic responses.

Studies by (Caboral-Stevens et al., 2020) indicate that a lack of pharmacology knowledge among undergraduate students can lead to medication errors in hospital settings. Lack of sufficient knowledge can lead to students not selecting the most appropriate interventions pertaining to the administration of medications for different conditions. Students may not be informed about the pharmacokinetics, pharmacodynamics and the individual factors that inform the selection of drugs and administration of appropriate medications (Caboral-Stevens et al., 2020). Inadequate information on drugs can lead to underdose or overdose, which affects the therapeutic index of the drugs putting the patients at risk for adverse reactions. The students may face challenges in the calculation of appropriate dosages by considering the characteristics of the patients, or they may not understand the essence of dose adjustment in different patient populations, such as pediatric or elderly patients. Additionally, the students may not have adequate knowledge regarding the potential drug interactions of adverse effects. Failing to recognize drug interactions and contraindications often leads to adverse drug reactions.

The review by Joyline (2021) identifies different causes of medication errors, especially the role of communication breakdowns experienced among pharmacists, patients and healthcare providers during the administration of medication. Some of the factors implicated in the commission of medication errors include illegible handwriting, inaccurate transcription of the information on medications (Joyline, 2021). Inadequate knowledge of the side effects, contraindications and drug interactions are also major causes of medication errors. The risk of medication errors is more pronounced in institutions that have inadequate medication management systems, workflow deficiencies and lack of standardized protocols (Joyline, 2021). Inadequate staffing levels, fatigue, high workload and limited training of workers on safe administration of medications increase the likelihood of the workers committing medication errors.

The authors identify some examples of harmful practices that lead to the commission of medication errors, such as slicing or crushing of medications, inadequate administration of food or fluids with medications, failure to mix medications properly and improper administration of medications alongside enteral nutritional formulas as major causes of medication errors. The authors further emphasize that lack of knowledge of drugs, lack of adherence to medication guidelines and protocols, and distractions during the administration of medications can also lead to medication errors. Joyline (2021), while citing the study by the Medication Error Quality Initiative noted that repeated medication errors occur frequently and can cause harm to elderly patients, with common negligent errors including incorrect doses, expired medications, incorrect administration techniques, and errors in documentation or monitoring.

References

World Health Organization. “Medication Errors: Technical Series on Safer Primary Care.” Accessed on May 30^th from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;sequence=1

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: a focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025

Caboral-Stevens, M., Ignacio, R. V., & Newberry, G. (2020). Undergraduate nursing students’ pharmacology knowledge and risk of error estimate. Nurse Education Today, 93, 104540. https://doi.org/10.1016/j.nedt.2020.104540

Faraj Al-Ahmadi, R., Al-Juffali, L., Al-Shanawani, S., & Ali, S. (2020). Categorizing and Understanding Medication Errors in Hospital Pharmacy in Relation to Human Factors. Saudi Pharmaceutical Journal, 28(12). https://doi.org/10.1016/j.jsps.2020.10.014

Joyline F., G. (2021). Medication Errors in Nursing Homes – Standards, Neglect & Statistics. Nursing Home Abuse Guide. Accessed on May 30^th from https://nursinghomeabuseguide.com/negligence/medication-errors/

Kirkendall, E. S., Timmons, K., Huth, H., Walsh, K., & Melton, K. (2020). Human-based errors involving smart infusion pumps: A catalog of error types and prevention strategies. Drug Safety, 43(11). https://doi.org/10.1007/s40264-020-00986-5

Mulac, A., Hagesaether, E., & Granas, A. G. (2021). Medication dose calculation errors and other numeracy mishaps in hospitals: Analysis of the nature and enablers of incident reports. Journal of Advanced Nursing, 78(1). https://doi.org/10.1111/jan.15072

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ Perceived Causes of Medication Administration Errors: A Qualitative Systematic Review. The Joint Commission Journal on Quality and Patient Safety, 47(1). https://doi.org/10.1016/j.jcjq.2020.09.010

World Health Organization. (2018). Medication Without Harm. Accessed on May 30^th from https://www.who.int/initiatives/medication-without-harm

Annotated Bibliography

The journal describes the different criteria used to classify the medication errors and emphasizes the need to have a standard recommendation for preventing medication errors. It calls for experts globally to identify new guidelines that can be used to battle the high number of medication errors reported. Nurses are advised to collaborate with others to prevent medication errors.

This journal focuses on human factors as a cause of medication errors. Semi-structured interviews with pharmacists and other healthcare workers were used to collect data on personal fatigue and burnout and their influence on committing medication errors. It further provides strategies that can be adopted to keep medication errors at bay.

This qualitative systematic review explores the perceptions held by the nurses on the causes of medication errors in the healthcare settings. Lack of awareness and knowledge-based factors were the major causes of medication errors identified by the review. It recommends that organization should offer healthcare workers training on medication errors to enhance their performance.

One hundred sixteen incident reports on medication errors were reviewed by this journal. The study established that hospitals with a high number of numeracy errors reported an increased number of medication errors that have adverse health outcomes. Introduction of training programs use of standardized protocols and technology was recommended to help mitigate medication errors.

Infusion pump errors as a cause of medication errors were discussed in this journal. It established that over 4000 injuries that can be prevented occur at each hospital every year. The authors conclude that even though smart pumps have been introduced as a means of mitigating these errors, they have also been implicated in causing some of the reported errors.

The journal has identified personal, contextual, and knowledge-based factors as major causes of medication errors. Insufficient knowledge of the workers in pharmacology has also been implicated in contributing to these errors. The authors recommend that the healthcare organizations should provide adequate education and supervision of students and novice nurses.

World Health Organization. (2018). Medication Without Harm. Accessed on May 30^th from https://www.who.int/initiatives/medication-without-harm

The website discusses different factors that lead to medication errors and risks to patient safety. Some of the factors identified include issues with staff training, workflow deficiencies and patient-related factors. The authors identify poor communication between healthcare workers and patients as a major cause of medication errors.

World Health Organization. “Medication Errors: Technical Series on Safer Primary Care.” Accessed on May 30^th from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;sequence=1

The authors identify lack of healthcare workers knowledge of the drug pharmacokinetics, pharmacodynamics and side effects as significant causes of medication errors. Similarly, a lack of adequate training on the correct techniques for administering medications may lead to medication errors that pose significant patient safety issues.

The website authors identify negligence, understaffing and distractions as the main causes of medication errors in the hospital setting. The authors stress that healthcare workers should have knowledge and adhere to protocols when administering medications. It recommends that healthcare institutions should conduct regular audits on medication administration to establish if the healthcare workers are compliant.

Synthesis Assignment Description: (please make any and all corrections that are needed based on your professor’s comments from the last submission)

Prepare the Literature Review section of your paper. Begin with an introductory paragraph that describes your search parameters and what databases were used. Be sure to avoid first person (I, we, me, us, etc.). Include at least one paragraph for each of your sources chosen in your Annotated Bibliography. This is not a repeat of the annotations in the annotated bibliography, but should be written as an essay that flows easily from one point to the next. Remember, your literature review should be at least seven paragraphs (eight for full credit on the final paper), but not more than twelve paragraphs. Each paragraph should be at least three sentences in length, but only contain one or two main points and support. Review your APA resources for how to properly cite references in your text. This is where you will apply in-text citation rules, as each paragraph will indicate the reference from which the information is taken.

Also prepare your reference page. Please review your APA resources as mentioned previously. Submit the entire document. However, only the literature review and reference page will be graded in this module.

M6 Assignment UMBO – 4

M6 Assignment PLG – 2

M6 Assignment CLO –2, 3, 4, 5, 6, 7

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Instructions & SpecificationsSubmissionsRubric

Start by reading and following these instructions:

Study the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.

Consider the discussion and the any insights you gained from it.

Review the assignment rubric and the specifications below to ensure that your response aligns with all assignment expectations.

Create your assignment submission and be sure to cite your sources, use APA style as required, and check your spelling.

The following specifications are required for this assignment:

Length: 7-8 to 12 paragraphs for the Literature Review

Structure: Submit with shell intact, complete the Literature Review and Reference section and review and make corrections to the past sections

References: Minimum of a total of 6 (six) sources (at least 4 journal articles and 2 websites) formatted in APA style in the reference section and citations in body of the text (6 journals and 3 websites for full credit on the final)

Format: Save your assignment as a Microsoft Word document (.doc or .docx).

Filename: Name your saved file according to your first initial, last name, and the module number (for example, “RHall Module 1.docx”)

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