Factors and Causes of Medication Errors Essay

Factors and Causes of Medication Errors Essay

 

Abstract

The factors and causes of drug errors in hospital settings are thoroughly reviewed in this paper. PubMed, BioMedCentral, and ScienceDirect are some databases used to find the articles used in the literature review. Only studies that addressed pharmaceutical errors in hospitals and identified the root causes and influencing factors were considered for the literature review. The study finds that pharmaceutical errors are still common in healthcare settings, frequently endangering patient safety and achieving successful healthcare outcomes. Poor patient-provider communication, inappropriate or inadequate technology utilization, a lack of established medication administration procedures, and insufficient stuffing are some of the issues studied in length as contributing to medication errors. Additionally, the paper offers suggestions to lessen the frequency of pharmaceutical errors. Overall, the study delivers insightful information about the complex factors contributing to drug errors in healthcare settings and offers valuable suggestions for enhancing patient safety.

Keywords: Medication errors

Factors and Causes of Medication Errors

Medication errors continue to be a serious and persistent problem that adversely affects patient safety and health outcomes, notwithstanding how demanding and sophisticated medical settings are. The errors involve a variety of avoidable occurrences that frequently have negative consequences on patient outcomes. Despite tremendous scientific and technological improvement, medication errors are still common in healthcare settings, necessitating thorough investigation and understanding of their underlying causes. Exploring various aspects, such as breakdowns in communication, system deficiencies, organization factors, and human factors that contribute to the high number of medication errors, can perhaps help address this issue. This paper aims to shed light on the different factors and causes of medication errors in healthcare settings to help bridge the gap between practical application and theoretical knowledge.

Literature Review

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 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.

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).

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 from 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 well-being 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 inadequate 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.

Different infusion pump errors 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 Medication Error Quality Initiative study, 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.

Literature Synthesis Discussion

The literature review provides excellent insights into the causes and factors that lead to medication errors. Synthesis of information from different credible sources helps to comprehensively understand different factors that interplay to lead to these errors. The discussion aims to go deeper into the implications of the evidence gathered from the literature review on the commission of medication errors in hospital settings by establishing the significance of factors such as distractions, interruptions, inadequate knowledge or training, technology-related problems, and organizational support.

Multiple authors share the same views on the causes of medication errors as identified in the literature review. For instance, Alrabadi et al. (2021) identified that nurses often face distractions and interruptions when administering medication errors, establishing it as one of the commonest causes of medication errors. Patients, coworkers, assistive personnel, and physicians often interrupt nurses. Faraj Al-Ahmadi et al. (2020) also share the same view, highlighting that nurses often face up to 10 interruptions each hour, causing medication errors and near misses. Alrabadi et al. (2021) also identified that poor penmanship and misinterpretation of medication orders due to poor handwriting was also a major cause of medication errors by administering wrong medications or incorrect dosages.

A study by Schroers et al. (2020) highlighted the influence of knowledge-based factors on medication errors. They highlighted how challenges in using technology in the hospital, calculation of medication dosages, and interpretation of guidelines and protocols as the major causes of medication errors. Kirkendall et al. (2020) highlight that all healthcare workers must be provided adequate training on these technologies when administering patients’ medications.

Healthcare organizations should be careful with adopting barcode scanning, computerized physician order entry (CPOE) systems, and Electronic Health Records, as their incorrect utilization can lead to errors. They also determined how the lack of training and clinical inexperience predisposed nurses to committing medication errors. Their views are embraced by Alrabadi et al. (2021) and Faraj Al-Ahmadi et al. (2020), who also underscored the influence of lack of clinical experience and inadequate training in leading to medication errors. The lack of sufficient knowledge, especially the lack of pharmacology knowledge among undergraduate students, has been explored by Caboral-Stevens et al. (2020) and how it can contribute to medication errors. Without adequate knowledge, these students may not select the most appropriate medications for various conditions, putting the patients at risk of adverse drug events.

Studies by Mulac et al. (2021) focused on the risk factors related to numeracy errors during the administration of medications. They advocated for the resilience of medication systems and the deviations nurses experience when preparing intravenous medications. Their views align with those proposed by Kirkendall et al. (2020) on adopting smart infusion pumps that rely on accurate information provided by Electronic Health Records (EHRs) to reduce medication errors.

The factors contributing to medication errors have also been discussed comprehensively by different authors in the literature review. Apart from Alrabadi et al. (2021) highlighting the sources of distractions and interruptions from other humans in the workplace, Faraj Al-Ahmadi et al. (2020) also delves into the effects of distractions and perceive them as multifactorial issues from heavy workload, poor compliance with policies and lack of support from the organizations. The influence of the heavy workload and fatigue as causes of medication errors have been explored by Faraj Al-Ahmadi et al. (2020), who established that workers often reported causes of moderate fatigue and required frequent breaks to recharge to prevent medication errors.

Similarly, Schroers et al. (2020) conclude that fatigue and physical exhaustion that results from understaffing and heavy workloads are major causes of medication errors. Faraj Al-Ahmadi et al. (2020), Schroers et al. (2020), Mulac et al. (2021), and Joyline (2021) all have the same views on the contribution of inadequate training and knowledge as the cause of medication errors. The lack of understanding and knowledge of the medications, their contraindications, side effects, and the potential drug interactions often lead healthcare workers to commit medication errors. Faraj Al-Ahmadi et al. (2020) specifically identify how implementing training programs and effective communication in healthcare settings can help address these gaps.

The theme of communication breakdowns as the cause of medication errors was also prominent in the literature review. All the authors have a consensus that effective communication among healthcare workers can greatly reduce the number of medication errors reported. Alrabadi et al. (2021) and Joyline (2021) stress how communication breakdowns can negatively impact healthcare outcomes. Communication breakdown can manifest due to illegible handwriting, and inaccurate medication-related information transcription often leads to errors.

Alrabadi et al. (2021) and Joyline (2021) recognize that institutions with a lack of standard medication protocols, deficiencies in workflows, and inadequate medication management systems were at the highest risk of facing medication breakdowns and often experiencing medication errors. They advocate for accurate transcription of medication information, legible and clear documentation, and enhanced communication channels among healthcare professionals to help decrease medication errors.

Optimization of healthcare workflows can help to reduce the occurrence of medication errors and promote patient safety. The roles and responsibilities of each team member should be well defined to ensure that each one knows their tasks and how and when to communicate with each other to prevent any errors. This enhances the seamless exchange of information and mitigates any omissions or miscommunication. The existing processes should also be reviewed regularly to identify any opportunities for improvement. For instance, the root cause analysis of the causes and factors involved in medication errors, gathering worker feedback, and analyzing near-miss incidents can be done (Kirkendall et al., 2020). Addressing barriers in communication and ensuring that information flows seamlessly between different healthcare workers can enhance the safety of patients.

Conclusion

Medication errors in healthcare settings remain a prominent challenge that puts the patient’s safety at risk. The paper has comprehensively reviewed the factors that lead to medication errors. A single factor does not cause medication errors but rather an interplay and interaction of different individual, organizational and system factors. Several recommendations have been provided to help solve this issue, such as the enhancement of communication between different healthcare workers and the patients, promotion of a culture of patient safety, increasing the number of healthcare workers in the hospitals and conduction of regular audits on the administration of medications. It is hoped that the paper will contribute to the ongoing efforts to enhance the safety of patients in healthcare settings by raising awareness of this issue and the appropriate interventions to reduce the occurrence of medication errors. If healthcare workers implement these recommendations, they can significantly improve the safety of the patients and improve healthcare outcomes.

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References

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. (2016). 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

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

Annotated Bibliography

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

The journal describes the different criteria used to classify 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 the occurrence of medication errors.

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

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.

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

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

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

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

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.

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

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 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 2023 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. (2016). Medication Errors: Technical Series on Safer Primary Care. Accessed on May 30^th 2023 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.

Joyline F., G. (2021). Medication Errors in Nursing Homes – Standards, Neglect & Statistics. Nursing Home Abuse Guide. Accessed on May 30^th 2023 from https://nursinghomeabuseguide.com/negligence/medication-errors/

The website authors identify negligence, understaffing and distractions as the leading 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.

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Synthesis Paper Assignment:

Prepare a one to two paragraph conclusion to your paper. Prepare the abstract section (150-250 words in a block paragraph). The abstract is the 2nd page of the paper and it has its own page. Submit your final paper with all corrections completed. In other words, be sure you review all of your professor’s correction from your previously submitted synthesis papers to ensure this paper is correct. Submit your entire completed paper. The entire synthesis paper will be graded at this time.

The synthesis paper was based on a healthcare topic of your choice. It is in APA format and was completed over several modules. The final synthesis paper will be graded during Module 8. The following components will be included in the paper:

Title page, page #s

Abstract

Body

Introduction paragraph with thesis statement

Literature Review section

Introductory paragraph explaining search parameters and databases used

At least 7 paragraphs, but no more than 12.

At least six scholarly sources (4 journals and 2 websites)

Not simply annotations, but an essay that flows from point to point

Discussion section

Two to five paragraphs that apply the literature review to your topic, drawing conclusions and supporting the thesis statement

May contain practice examples

Conclusion

One to two paragraphs that support and finalize the thesis argument

Reference page

Annotated bibliography

Must contain at least four scholarly literature sources and two credible websites

Must contain annotations

M8 Assignment UMBO – 4

M8 Assignment PLG – 2

M8 Assignment CLO –1, 2, 3, 4, 5, 6, 7

Assignment Dropbox

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: 6 to 12 pages; answers must thoroughly address the questions in a clear, concise manner

Structure: Entire shell components with all sections completed and corrected

References: At minimum a total of 6 (six) sources (at least 4 journal articles and 2 websites) (9 sources total for full points) formatted in APA style in the reference section and annotated bibliography, and citations in body of the text