Literature review on medication administration errors

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences, 32(3), 1038-1046.

The article by Hammoudi et al 2018 outlines that most healthcare facilities encounter the challenge of sustaining patient’s safety as medication administration being the vital item in attaining optimistic healthcare outcomes. There is a need to implement the best plans for preventing MAEs as they lead to both mortality and morbidity. Some of the vital root causes of MAEs identified by the article include confusion from drugs with alike names, failure to apply the evidence based activities in healthcare which is important in providing practical plans in ensuring quality healthcare to patinets,poor communication between the interdisciplinary members, poor documentation and inability to read drug orders due to bad handwriting. Knowledge differences between the health practitioners, excessive workloads to healthcare providers which results to excessive tiredness, frequent rotation of staffs which results to unclear orders and insufficient medication packaging are some other causes of MAEs. Additionally, lack of collaboration between nurses, doctors and patient is another main cause of MAEs in healthcare. This article is very important to the healthcare providers as it will help them identify the root causes of MAEs and implement effective strategies to prevent them for the patients well being.

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1), 1–9. https://doi.org/10.1186/s12912-020-0397-0

Wondmieneh et al 2020 illustrates risky medication activities as some of the key causes of MAEs in healthcare facilities. The article also states that the errors are prone to occur in any medication administration phase to any patient. The vital role of nurses is to prevent these medication errors from occurring by strictly following the established healthcare provisions. Some of the crucial MAEs causes identified by the article are wrong timing when administering doses to patients, wrong dose administration to inpatients which results mainly from wrong diagnoses, using wrong route to administer a drug, giving drugs to unintended patients. Additionally, poor documentation which may include recording wrong information about a patients and the omission of doses which could have been important to the recovery of a patient. . This article is significant to the healthcare providers as it entails in detail on the significant strategies that can be used to reduce MAEs in healthcare facilities. It also emphasizes on the six rights to administration of medication which should be followed by the healthcare practitioners to enhance the reduction of MAEs. These six rights include; administering drugs to the right patient, using the right medication at the right time, using a correct route, making sure it’s the right drug and ensuring the use of the right documentation. This article further suggest that health workers should be trained regularly on the safe and effective administration of drugs to enhance the minimization of these MAEs

Keers, R. N. (2018). (2018). Plá cido M, Bennett K, Clayton K, Brown P, Ashcroft DM. What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLoS One, 13(10), e0206233.

The article by Keers 2018 outlines that MAEs are regular risks encountered by mental ill patients ,but lack of thorough studies to determine the causes of these errors restrains the implementation of effective prevention strategies. Some of the major causes discussed in the article include unbalanced staff skill mix which leads to knowledge gaps between the health practitioners and understaffing which causes work overloads to nurses. Another primary MAEs cause is nurses getting distracted or interrupted while administering drugs. These distractions maybe from phones or talking with other people while working. Additionally, concerns with how drug administration task was to be addressed and communication challenges between the multidisciplinary teams are other major causes of MAEs. The article is significant to health practitioners since it outlines the major causes of MAEs in a mental facility and this will help them come up with an effective plan to mitigate these MAEs. Additionally, recruitment of enough staff is encouraged to reduce the impact of work overloads to healthcare providers as this causes fatigue which later leads to MAEs. Further ,the article advocates for proper training of healthcare practitioners on the proper and safer ways to administer drugs to avoid confusions on how the medication administration task should be addressed.

Evidence-Based and Best Practice Strategies to Reduce Falls in Health Facilities

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). (2022). Medical Error Reduction and Prevention. In StatPearls. StatPearls Publishing.

Rodziewicz et al., 2022 as the author of the article acknowledges that MAEs are usually caused by two major types of errors and they include the errors of omissions and commission. The whole healthcare team must take part in ensuring the provision of safety to patients. identifying the patients danger and risks will help to prevent MAEs. this will be possible since the health practitioners will know how a certain patient reacts to different medication and he/she will avoid administering drugs that a patient is allergic to. The article also eradicates that double checking the identity of a patient ,improving communication by getting results to the right person quickly and correctly labelling drugs during preparation time are vital in minimizing the medication administration errors. Further the use of alarm devices and ensuring that alarms on drug equipment’s are checked when heard. The article also delves that surgery mistakes can be prevented by double checking all details before the surgery starts to ensure that the correct surgery is done to the correct body part. also healthcare providers are advised to take more time with patients prescribed chemotheraupitic and anticougalants to observe their reactions to those medications. The health practitioners should review this article as it will help them avoid interruptions during medical administrations.

Johansen, J. S., Havnes, K., Halvorsen, K. H., Haustreis, S., Skaue, L. W., Kamycheva, E., Mathiesen, L., Viktil, K. K., Granås, A. G., & Garcia, B. H. (2018). (2018). Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial. BMJ Open, 8(1), e020106. https://doi.org/10.1136/bmjopen-2017-020106\

The article by johansen mainly focuses on integrated medicine management (IMM) model which is a multifactorial multidisciplinary strategy focusing on optimizing patient drug therapy through out their stay in a hospital. The article outlines that in order to improve the process of medicine management, medication reconciliations ,drug reviews and educating the patients are very effective. Further , the article entails that IMM has been effective in improving the communication of drug information at the conversion point. Patient counselling which is build to meet individual’s need is also very essential in preventing MAEs in healthcare. Healthcare facilities are encouraged to integrate skilled and experienced health practitioners in daily drug administration as this would boost the application of quality healthcare. Additionally, the health facilities are urged to recruit enough staffs to minimize pressuring experienced because of overloading the healthcare providers. Further double checking the information of an inpatient is encouraged as it helps in the minimization of administering drugs to the wrong patients.. The article is important to healthcare providers because it ascertains the strategies they can use to prevent potential MAEs in healthcare.

Mieiro, D. B., Oliveira, É., Fonseca, R., Mininel, V. A., Zeapplicatrion m-Mascarenhas, S. H., & Machado, R. C. (2019). (2019). Strategies to minimize medication errors in emergency units: an integrative review. Revista brasileira de enfermagem, 72(suppl 1), 307–314. https://doi.org/10.1590/0034-7167-2017-0658

Mieiro et al 2019 is the author of this article. The main aim of this article is to asses all the strategies that can be used by nurses to reduce the MAEs in healthcare. The first strategy is education aiming to reduce the MAEs. This intervention involves the significant training of health professionals and medical students on the proper and safe way to administer drugs. Education can be offered through lectures ,campaigns and clinical stimulations. Exposing students to healthcare experiences in a conducive surrounding helps to impact optimistic learning experiences. The second strategy discussed by this article is the organizational strategies aiming to prevent medication errors. The structure in which people are inserted in an organization directly corresponds with the errors hence engaging people at all levels of work will help increase their performance. Also ,the right management of risky drugs should be examined as a crucial issue in healthcare practice. The third strategy is the use of new technologies in work process in MAEs reduction. Technologies like computerized systems for prescriptions helps to minimize errors from bad handwriting. Also, use of barcode system which helps identify different medication can enhance safety when administering drugs. Health practitioners should review this article as it will help them asses the use of new technology to prevent MAEs.

Koyama, A. K., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). (2020). Effectiveness of double-checking to reduce medication administration errors: a systematic review. BMJ quality & safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

The article by Koyama et al 2020 highlights on how effective double checking is in minimizing the MAEs in heathcare. The article depicts that there is minimal evidence to proof how double checking is effective with the reduction of MAEs. Additionally the article outlines that there are a lot of significant disparities and lack of coherency about how to perform the double check. Generaly there is no firm evidence base to hold up its use since there is lack of a good quality study and also lack of positive outcomes in the minimization of medication errors and patient risks. Double checking can be very hard to de-implement since it is an ineffective way of preventing MAEs hence it is very likely to face a lot of resistance from the healthcare practitioners. However, double checking is a significant requirement while signing off information in medical administration computerized systems. There is still the need for research to direct the vital questions about where and when double checking is effective to patients safety results. This article is very crucial to the health practitioners since it will help them reconsider using the double check strategy due to its in effectivity.

Improvement plan

Manias E. (2018). (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert opinion on drug safety, 17(3), 259–275. https://doi.org/10.1080/14740338.2018.1424830

The article by Manias 2018 focuses on evaluating the effect of interdisciplinary collaboration in hospitals on medication errors prevention. Medication errors are regularly affected by poor communication hence interdisciplinary collaboration is a vital way of enhancing communication between health practitioners in healthcare practice. The article outlines five contrasting items of interdisciplinary corporation pinpointed in previous research work; communicating using tools comprising guidelines, protocols and communication logs; engagement of pharmacists in interdisciplinary groups, integrative medication review on admission and at dismissal, corporate workshops and conferences and complexity of role differentiation and surroundings. While past strategies focused at enhancing the interdisciplinary corporation led to minimization of medical errors, yet these medication errors continued to occur. Hence ,health professionals are encouraged to include diverse individuals e.g. speech pathologists ,social workers and physiotherapists in addition to nurses, doctors and patients in the interdisciplinary committee. This will help to give future opportunities for improved interdisciplinary cooperation in medical safety.. Further ,more work is required on the examination of the changed approaches to interdisciplinary cooperation in situations engaging the movement of patients across the change of care and health practitioners involvement with digital medical records. This article will help the healthcare providers to improve on the interdisciplinary collaboration strategy so as to get more positive outcomes on the MAEs reduction.

Kron, K., Myers, S., Volk, L., Nathan, A., Neri, P., Salazar, A., Amato, M. G., Wright, A., Karmiy, S., McCord, S., Seoane-Vazquez, E., Eguale, T., Rodriguez-Monguio, R., Bates, D. W., & Schiff, G. (2018). (2018). Incorporating medication indications into the prescribing process. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 75(11), 774–783. https://doi.org/10.2146/ajhp170346

The article is written by Kron et al., 2018 and it’s main purpose is to discuss how integration of medication indications into the procedure of enhancing the safety of patients. Patient specific drug indication is a vital information required for safe use of medication yet it’s commonly absent in many prescriptions. Cooperating indications enhances safer prescribing by; avoiding look-alike/sound alike errors, enhancing the selection of drugs of choice, helping in communication among the healthcare members, strengthening the understanding of a patient and the arrangement of drug lists to facilitate medication adjustments. The rise of digitalized prescribing has led to the need for more groundwork for integrating indications in the CPOE procedure of prescription. Further, it is important to build CPOE systems to constructively and efficiently include indications into prescriber functionalibility and increase ways that can best achieve that. The article is very vital to health practitioners as it will help them to know the effective ways of improving the prescription work so as to reduce MAEs.

Schnipper, J. L., Mixon, A., Stein, J., Wetterneck, T. B., Kaboli, P. J., Mueller, S., Labonville, S., Minahan, J. A., Burdick, E., Orav, E. J., Goldstein, J., Nolido, N. V., & Kripalani, S. (2018). (2018). Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ quality & safety, 27(12), 954–964. https://doi.org/10.1136/bmjqs-2018-008233

The article by Schnipper et al 2018 depicts on the effect of the improvement of medical reconciliation strategy in the reduction of MAEs in healthcare facilities. The article outlines that medical reconciliations minimizes discrepancies which are a regular form of medication errors and are capable of resulting to patient harm. Consistency in reconciliation of the patients medication ensures that the patient and his/her care provider are on the line and it guarantees that best methods are used to address the needs of the patient. However, apply that strategy is very difficult in real world-setting since the sources of medication information are always scattered in many different places. The application of a multifarious medication reconciliation quality improvement strategy decreases the some medication errors though it is ineffective to the harmful medication discrepancies. Hence there is still the need to research more on how and when it should be used in healthcare facilities. This article is vital to the healthcare providers as it will help them asses the importance and when to use medication reconciliation.

Human resources and financial resources

Mahlknecht, A., Krisch, L., Nestler, N., Bauer, U., Letz, N., Zenz, D., Schuler, J., Fährmann, L., Hempel, G., Flamm, M., & Osterbrink, J. (2019). (2019). Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT. BMC geriatrics, 19(1), 257. https://doi.org/10.1186/s12877-019-1263-3

Mahlknecht et al., 2019 is the author of this article. The article focuses on the impact of training and structuring medication evaluation on drug effectiveness. For the improvement plan to be implemented, effective utilization of both human and financial resources will be required. Proper training and educating of the health professionals will be effective in ensuring proper and safety administration of drugs which will eventually lead to the reduction of MAE . Education can be provided in the form of lectures or campaigns through the online platforms while training can be offered through interproffessional workshops. Also, the recruitment of enough staff is vital in the mitigation of MAEs as it allow easy division of labor without over loading any one. A clear budget plan is essential for the plan to ensure that everything fall into place. The budget should be inclusive of finances to buy digitalized system which will efficiently help to minimize the MAEs. The article is significant to the healthcare professionals as it helps them plan for the resources required to be utilized so as to mitigate the MAEs.

Wei, W., Coffey, W., Adeola, M., & Abbasi, G. (2021). (2021). Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, zxab287. Advance online publication. https://doi.org/10.1093/ajhp/zxab287

The article by Wei et al 2021 focuses on the financing of a health care facility to acquire modern technology systems which mainly aids in reducing the MAEs in healthcare. The article depicts that incorporating smart pumps together with electronic health records (EHR) minimizes medication errors by computerized pump programming and EHR documentation. Pump-EHR combination results to safe giving of endovenous drugs basing on enhanced medication library adherence and more precise computerized pump programming. An estimated budget of $100000 is required in order to purchase the smart pumps. The healthcare practitioners need to review this article as it will help them to know the importance of incorporating smart pumps with EHR in order to minimize the MAEs.