Factors and Causes of Medication Errors Literature Review Essay

Factors and Causes of Medication Errors Literature Review Essay


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.

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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 identifies 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.



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 30th 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

Annotated Bibliography

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

Prepare the Discussion section of your paper. Submit the entire document. However only the discussion section will be graded in this module. The discussion section should contain two to five paragraphs and should be a discussion of how the literature review impacts your topic. Go back to your thesis statement and be sure to clearly apply your literature review to your thesis statement. This is where you might choose to add practice examples.


M7 Assignment UMBO – 4

M7 Assignment PLG – 2

M7 Assignment CLO –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: 2-5 paragraphs for the Discussion; answers must thoroughly address the questions in a clear, concise manner

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

References: If any of the sources are used in the Discussion they are to be formatted in APA style citations in body of the text

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

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