Improvement Plan Tool Kit

Medication administration errors (MAEs) cause a variety of health issues and even death in patients, thus it’s critical to raise awareness and improve understanding among healthcare workers. Nurses and other health practitioners must determine the fundamental cause of MAEs in order to quickly identify methods to manage such health issues. They must also identify the dangers of drug errors before developing feasible strategies to address the issues. The use of evidence-based practices (EBP) by healthcare providers would improve the quality of care provided to patients. Despite the fact that healthcare institutions have urged for health practitioners to report drug errors as soon as possible, there are a number of issues that must be addressed right away. To encourage the development of effective ways to impact the positive attitude of health practitioners, care providers must first identify the impediments. This study will look at twelve annotated sources that are divided into four categories: the cause of MAEs, the impact of MAEs, evidence-based measures to preventing medication mistakes, and barriers to MAE reporting. Every source is evaluated for its use to the role group in charge of implementing safety enhancements and its potential to reduce MAEs. Finally, the sources provide compelling reasons and relevant circumstances for the target audience’s utilization of the tool kit.

MAEs in HealthCare: What Causes Them?

1. Alemu, T. Belachew, and I. Yimam (2017). A cross-sectional study at two public hospitals in Southern Ethiopia looked at medication administration errors and the factors that contributed to them. 68-74 in International Journal of Africa Nursing Sciences.

 

MAEs are identified as substantial causes of mortality and morbidity among patients in the healthcare system, according to the article. According to Alemu, Belachew, and Yimam (2017), exhaustion caused by work overload among nurses leads to medication errors. MAEs in healthcare are also caused by incompetence among undergraduate intern nurses. Medication errors can also be caused by a lack of training and personnel among health professionals.

 

To lower the risk of MAEs, the authors underline the significance of good verbal communication between doctors and nurses. To avoid work overload among health practitioners, the nurse-to-patient ratio should be high. As a result, the nurses will be under little or no pressure to meet all of the patients’ needs, resulting in fewer medication errors. Possible policies should limit various sources of distraction, such as phone calls and continual storytelling among coworkers. Doctors should write in readable handwriting so that nurses and pharmacists can read and understand it. This article should be used by health practitioners and nurses to identify the key causes of MAEs in healthcare and develop appropriate mitigation methods.

 

1. A. Tariq, R. Vashisht, A. Sinha, and Y. Scherbak (2021). Preventing Medication Dispensing Errors StatPearls Publishing, StatPearls Publishing, StatPearls Publishing, StatPearls Publishing, StatPearls Publishing,

 

The article underlines that the United States has a large number of over-the-counter pharmaceuticals and around 6,800 prescription medications (U.S.). Because the public uses thousands of lotions, potions, herbs, and other health supplements to cure their ailments, health practitioners encounter obstacles in patient care. As a result of the large number of chemicals available on the market, practitioners are more prone to dispense or prescribe medications incorrectly. According to the authors, around 7,000 to 9,000 persons die each year in the United States owing to drug errors. The annual expense of caring for patients who have had medication-related mishaps exceeds $40 billion. Patients incur physical and psychological harm as a result of prescription errors, in addition to the financial costs.

 

The article assists health practitioners in reducing MAEs by identifying the most common pharmaceutical errors and proposing appropriate solutions. Tariq et al. (2021) discuss important tactics for avoiding medication errors and provide a full overview of interprofessional team approaches to medication error reduction. MAEs are prevalent problems in healthcare, costing billions of dollars and causing significant death and morbidity across the country. This article is important for healthcare professionals to read because it promotes a multi-faceted approach to patient safety prevention and education.

 

10. Wondmieneh, W. Alemu, N. Tadele, and A. Demis (2020). A cross-sectional study in tertiary hospitals in Addis Ababa, Ethiopia, looked at medication delivery errors and contributing factors among nurses. BMC nursing, vol. 19, no. 4, doi:10.1186/s12912-020-0397-0

 

The leading cause of MAEs in healthcare, according to the authors, is inappropriate pharmaceutical practices. Nurses play a key role in preventing medication errors by adhering to policy guidelines. Medication errors, according to Wondmieneh et al. (2020), can occur at any point during the administration of medication to patients. The article categorizes the most common types of MAEs in healthcare, such as giving patients the wrong dose or the wrong medicine. Medication is often given to the wrong patient at the wrong time or to the wrong patient entirely. Nurses may overlook critical patient information and fail to administer critical doses that might have aided the patient.

 

The article is important for nurses and other health professionals since it outlines many ways for reducing drug errors in health care and ensuring patient safety. Furthermore, the authors stress the necessity of avoiding MAEs by adhering to the basic rights to medicine administration. Health care providers should use the suitable pharmaceutical route, provide the correct amount, administer medication to the appropriate patient, use the correct drug at the appropriate time, and keep accurate records. Nurses and other health professionals should have their workloads reduced by hospital administrators.

 

Medication Administration Errors’ Impact on Health-Care

 

10. A. Elliott, E. Camacho, D. Jankovic, M. J. Sculpher, and R. Faria (2021). In England, an economic examination of the prevalence of prescription errors, as well as the clinical and economic costs associated with them. 96–105 in BMJ quality & safety. https://doi.org/10.1136/bmjqs-2019-010206

 

The article provides national estimates of the financial and clinical costs of prescription mistakes in the National Health Service of England (NHS). According to Elliott et al. (2021), around 237 million drug errors occur in England each year. According to the authors, 38.4% of drug errors occur in primary care, with 72 percent having no or low risk of damage. A total of 66 million drug mistakes are clinically serious. Prescription drug errors in primary care account for 34% of all clinically significant medication errors. The cost of preventable adverse drug events (ADEs) to the NHS is estimated to be over £98,462,582 per year, according to the authors. Around 1708 deaths have been linked to medication mistakes. As a result, MAEs have a major impact on the quality of care.

 

Healthcare facilities must prioritize patient safety by involving qualified and experienced practitioners in the administration of medication to patients. MAEs cause health issues, which have a negative impact on patients’ well-being and force healthcare systems to pay excessive costs. This article can be used by health professionals to determine the economic and clinical consequences of MAEs. The article can also assist nurses in avoiding MAEs and achieving desired health outcomes.

 

Long, B., Robertson, J. J., and Robertson, J. J. (2018). Medical Error and Its Impact on Health Care Providers: Suffering in Silence Journal of emergency medicine, vol. 54, no. 4, pp. 402–409. https://doi.org/10.1016/j.jemermed.2017.12.001

 

The impact of MAEs on engaged care providers is discussed in this article. Furthermore, Robertson and Long (2018) propose plausible explanations why MAEs may have a negative impact on care providers’ mental health. The authors also provide practical strategies for health-care facilities and practitioners to mitigate MAEs’ negative effects. Post-MAEs, care providers and physicians may experience melancholy, fear, worry, embarrassment, and guilt, among other negative emotions. Individual culpability in medication and a culture of perfectionism exist, which helps to mitigate the bad effects. Despite their need for adequate support, several physicians lack administrative and personal help. As a result, a lack of support may exacerbate psychological distress.

 

The authors of this article suggest potential strategies to prevent MAEs, which may be useful to health practitioners. Counseling, learning from oversight, and addressing oversights with others are all important, according to Robertson and Long (2018). The authors also emphasize the importance of caregiver wellness in patient care. Unintentional drug errors will always occur in the medical system. To improve quality of care, however, healthcare management must focus on providing treatment and patient health.

 

2016. Härkänen, K. Vehviläinen-Julkunen, T. Murrells, A. M. Rafferty, and B. D. Franklin. Härkänen, Vehviläinen-Julkunen, K. Vehviläinen-Julkunen, K. Vehviläinen-Julkunen, K. Vehviläinen-Julkun (2019). Incidences of medication administration errors and mortality recorded in England and Wales from 2007 to 2016. RSAP, 15(7), 858–863. Research in social and administrative pharmacy, 15(7), 858–863. https://doi.org/10.1016/j.sapharm.2018.11.010

 

According to the writers of this article, some drugs pose additional hazards to patients after they are taken. The drugs are considered high-alert medications, which necessitate extra attention. Anesthetics, chemotherapeutic pharmaceuticals, epidural medications, anti-thrombotic medications, dialysis solutions, and intrathecal medications are among the substances. MAEs, according to Härkänen et al. (2019), cause patients to suffer life-threatening injuries, incur additional costs, experience discomfort and agony, and require a lengthy hospital stay.

 

The authors emphasize the necessity of understanding the type of medication supplied to patients in this paper, which nurses and other healthcare practitioners should read. As a result, this would assist nurses in identifying high-risk drugs that could harm patients if administered incorrectly. The article is useful and informative since it assists health care providers in identifying drugs that require extra attention in order to avoid medication errors. As a result, caregivers will always take necessary safeguards. Nurses and other practitioners are reminded that it is their responsibility to improve the well-being of their patients.

 

In healthcare, evidence-based ways to address MAEs

 

Ciapponi, A., Fernandez Nievas, S. E., Seijo, M., Rodrguez, M. B., Vietto, V., Garcia-Elorrio, E., Garca-Perdomo, H. A., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Garcia-Elorrio (2021). In hospital settings, reducing medication mistakes in adults. CD009985, in The Cochrane Database of Systematic Reviews, 11(11), https://doi.org/10.1002/14651858.CD009985.pub2.

 

MAEs are defined in the article as activities that can lead to inappropriate pharmaceutical use or patient damage. Nonetheless, the patient or the healthcare provider has complete control over the drug. MAEs that occur among in-patient adults, according to Ciapponi et al. (2021), may result in increased expenses, harm, or death of the patients. The goal of this study is to determine the efficacy of intervention techniques employed by healthcare facilities to minimize MAEs in people in those settings. As a result, the paper looks into the efficacy of the measures used in healthcare to avoid MAEs. The implementation of policies that would drive health practitioners to follow established policies in healthcare, digital technologies, and improved multidisciplinary cooperation are some of the significant interventions used by health professionals to mitigate MAEs.

 

To improve the administration of quality treatment, healthcare institutions should engage experienced, qualified, and competent health practitioners to deliver medication. In addition, the management should hire adequate healthcare staff to reduce labor overload during various medical situations. As a result, health professionals are encouraged to employ evidence-based strategies to manage a variety of health problems. The article is significant for healthcare providers since it discusses potential drug errors and suggests remedies to improve patients’ health outcomes.

 

603. K. Koyama, C. S. Maddox, L. Li, T. Bucknall, and J. I. Westbrook (2020). A comprehensive review of the effectiveness of double-checking to prevent prescription administration errors. Quality & Safety in Medicine, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

 

In most healthcare settings, double-checking is the recommended standard practice for prescription delivery. The authors emphasize that double-checking high-risk medications and their effectiveness in lowering MAEs is still a work in progress. As a result, Koyama et al. (2020) conducted a comprehensive review of research evaluating the efficacy of double-checking medication to decrease errors. Nurses play an important role in ensuring patient safety by intercepting MAEs that are harmful to patients and the healthcare facility. In order to reduce MAEs in healthcare, the essay emphasizes the importance of double-checking.

 

Because it suggests a double-checking technique to reduce MAEs, the paper is valuable to healthcare providers. Because the technique reduces patient injury and lowers the number of MAEs, nurses are also motivated to double-check medication administration. The healthcare organization and nurses must work together to prevent drug errors. As a result, double-checking allows care providers to ensure that the medication given to the patient is correct in order to avoid misdiagnosis. Double-checking has a number of advantages in terms of ensuring patient safety by lowering MAEs.

 

10. A. Mutair, S. Alhumaid, A. Shamsan, A. Zaidi, M. A. Mohaini, A. Al Mutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. (2021). Effective Medication Error-Prevention Strategies and Improving Reporting Systems Medicines, 8(9), 46, https://doi.org/10.3390/medicines8090046 (Basel, Switzerland).

 

Multiple countries’ population-based research has consistently shown extraordinarily high levels of MAEs and accompanying unnecessary deaths. The essay recognizes the relevance of an effective drug error reporting system as a metric for achieving patient safety. Changes to drug error reporting systems and improvement activities should strive to lessen the likelihood of future patients suffering damage. Mutair et al. (2021) wrote this study with the goal of discussing MAE reporting culture and generating efficient reporting ways. The authors make pertinent proposals for improving MAE reporting systems.

 

Reduced MAEs aid healthcare organizations and clinicians in providing patients with high-quality care. MAEs have become a widespread problem that is putting a strain on the healthcare system and causing harm to patients. Nurses can help prevent MAEs by using effective preventive strategies. The efficiency with which the obtained information is used to improve patient safety can be used to assess the efficacy of a reporting system. The article can be used by health practitioners to determine the characteristics of an effective MAE reporting plan. A reporting strategy should be secure, generate actionable recommendations, and prompt effective changes.

 

Obstacles to MAE reporting in health care

 

3. M. Hammoudi, S. Ismaile, and O. Abu Yahya (2018). Factors that contribute to medicine delivery errors, as well as why nurses don’t disclose them. 1038–1046 in Scandinavian Journal of Caring Sciences, vol. 32, no. 3. https://doi.org/10.1111/scs.12546

 

Several healthcare industries are having difficulties ensuring patient safety within the institution. The essay looks into the elements that contribute to MAEs, as well as why nurses fail to report them. In the healthcare setting, proper medicine administration is a critical component of achieving a beneficial outcome. According to Hammoudi, Ismaile, and Abu Yahya (2018), MAEs in healthcare result in a high rate of morbidity and mortality among patients admitted to hospitals. As a result, healthcare companies must employ the most effective strategies for reducing healthcare errors.

 

The challenges to reporting MAEs would be obvious to nurses and healthcare providers who read this article. Poor communication among interdisciplinary team members, for example, has resulted in the failure to implement evidence-based practices in healthcare, as well as difficulties understanding illegible handwritten medical instructions. Knowledge gaps among caregivers, staff rotations, inadequate pharmaceutical packing, and a high workload are among the major roadblocks. This article is beneficial to health practitioners since it will assist them in identifying significant barriers to reporting MAEs and initiating preventative measures for the patients’ health.

 

734. Lee Lee E. Lee E. Lee E. Lee (2017). Nurses at South Korean hospitals report medicine administration problems. Journal of the International Society for Quality in Health Care, 29(5), 728–734. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 29(5), 728–734. https://doi.org/10.1093/intqhc/mzx096

 

The author analyses current inequalities in what care providers consider MAEs in order to determine their readiness to report MAEs, as well as the considerable barriers to reporting any medical error based on the type of hospital. By sharing expertise and conveying essential information stored in an incident reporting system, MAE reporting provides a substantial chance to identify and correct medical errors that endanger patient safety. To guarantee patient safety, nurses must learn from their mistakes and report them to the appropriate authorities. According to Lee (2017), there were no significant differences in what nurses considered MAEs amongst nurses working in different types of hospitals. The number of incidents reported in different hospitals was shockingly low. Because of the potential for negative consequences and legal action, Korean nurses preferred filing an incident report to reporting MAEs to a physician, according to the author.

 

The article explains why it’s critical for healthcare providers to report MAEs by submitting an incident report. The findings of the study have significant implications for improving patient safety in healthcare settings. Furthermore, by requiring event reporting, healthcare organizations must make an extra effort at the organizational level to improve medication safety and reduce MAEs. To improve patient safety on MAEs, hospital management might design instructional programs. Finally, the information acquired by the author can be used to create strategies for removing barriers to reporting medical errors.

 

10. N. Rutledge, T. Retrosi, and G. Ostrowski (2018). Obstacles to hospital nurses reporting drug errors. 1941–1949, Journal of Clinical Nursing, 27(9-10). https://doi.org/10.1111/jocn.14335

 

The hurdles to reporting MAEs among hospital nurses are examined in this article. The reliability and validity of existing barriers to reporting medication errors were established by Rutledge et al. (2018). The authors state that MAEs are reported at the hospital from the time a physician orders medication until the time the patient receives medication while under the supervision of the staff. Before healthcare organizations can establish effective methods to eliminate medication errors, they must first understand the many reasons that prevent MAEs from being reported. When staff members fail to disclose drug errors, patient safety is always jeopardized. As a result, improvement activities are hampered in such situations.

 

Nurses and healthcare professionals who want to eliminate barriers to MAE reporting will find the material helpful. Nurses who report MAEs swiftly learn from a variety of factors in order to prevent future medication errors. Nurses rarely report MAEs because they are unable to discriminate between acceptable medical practice and medication errors in healthcare. When a medication error is disguised or no patient harm is apparent, nurses are less likely to report it. Under-reporting makes it difficult to obtain accurate data on pharmaceutical errors and prevents healthcare institutions from making necessary changes.

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

1. Alemu, T. Belachew, and I. Yimam (2017). A cross-sectional study at two public hospitals in Southern Ethiopia looked at medication administration errors and the factors that contributed to them. 68-74 in International Journal of Africa Nursing Sciences.

 

Ciapponi, A., Fernandez Nievas, S. E., Seijo, M., Rodrguez, M. B., Vietto, V., Garcia-Elorrio, E., Garca-Perdomo, H. A., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Garcia-Elorrio (2021). In hospital settings, reducing medication mistakes in adults. CD009985, in The Cochrane Database of Systematic Reviews, 11(11), https://doi.org/10.1002/14651858.CD009985.pub2.

 

10. A. Elliott, E. Camacho, D. Jankovic, M. J. Sculpher, and R. Faria (2021). In England, an economic examination of the prevalence of prescription errors, as well as the clinical and economic costs associated with them. 96–105 in BMJ quality & safety. https://doi.org/10.1136/bmjqs-2019-010206

 

3. M. Hammoudi, S. Ismaile, and O. Abu Yahya (2018). Factors that contribute to medicine delivery errors, as well as why nurses don’t disclose them. 1038–1046 in Scandinavian Journal of Caring Sciences, vol. 32, no. 3. https://doi.org/10.1111/scs.12546

 

2016. Härkänen, K. Vehviläinen-Julkunen, T. Murrells, A. M. Rafferty, and B. D. Franklin. Härkänen, Vehviläinen-Julkunen, K. Vehviläinen-Julkunen, K. Vehviläinen-Julkunen, K. Vehviläinen-Julkun (2019). Incidences of medication administration errors and mortality recorded in England and Wales from 2007 to 2016. RSAP, 15(7), 858–863. Research in social and administrative pharmacy, 15(7), 858–863. https://doi.org/10.1016/j.sapharm.2018.11.010

 

603. K. Koyama, C. S. Maddox, L. Li, T. Bucknall, and J. I. Westbrook (2020). A comprehensive review of the effectiveness of double checking to prevent prescription delivery errors. Quality & Safety in Medicine, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

 

734. Lee Lee E. Lee E. Lee E. Lee (2017). Nurses at South Korean hospitals report medicine administration problems. Journal of the International Society for Quality in Health Care, 29(5), 728–734. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 29(5), 728–734. https://doi.org/10.1093/intqhc/mzx096

 

10. A. Mutair, S. Alhumaid, A. Shamsan, A. Zaidi, M. A. Mohaini, A. Al Mutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. Almutairi, A. (2021). Effective Medication Error-Prevention Strategies and Improving Reporting Systems Medicines, 8(9), 46, https://doi.org/10.3390/medicines8090046 (Basel, Switzerland).

 

Long, B., Robertson, J. J., and Robertson, J. J. (2018). Medical Error and Its Impact on Health Care Providers: Suffering in Silence Journal of emergency medicine, vol. 54, no. 4, pp. 402–409. https://doi.org/10.1016/j.jemermed.2017.12.001

 

10. N. Rutledge, T. Retrosi, and G. Ostrowski (2018). Obstacles to hospital nurses reporting drug errors. 1941–1949, Journal of Clinical Nursing, 27(9-10). https://doi.org/10.1111/jocn.14335

 

1. A. Tariq, R. Vashisht, A. Sinha, and Y. Scherbak (2021). Preventing Medication Dispensing Errors StatPearls Publishing, StatPearls Publishing, StatPearls Publishing, StatPearls Publishing, StatPearls Publishing,

 

10. Wondmieneh, W. Alemu, N. Tadele, and A. Demis (2020). A cross-sectional study in tertiary institutions in Addis Ababa, Ethiopia, looked into medication administration errors and the factors that contributed to them. Nursing, BMC, vol. 19, no. 4, p. https://doi.org/10.1186/s12912-020-0397-0