Medication Error Research Paper

Medication is very important part of treatment, recovery and management of variety diseases. It has a long journey and many stages while it reaches the patient and at any of these stages an error can occur. This assignment explores types of medication errors, statistics, factors contributing to medication errors, failures to report and prevention.

National Patients Safety Agency medication error defines as ‘The process of prescribing, dispensing, preparing, administering, monitoring or providing medicine advice, regardless of whether harm has occurred or was possible’ (NPSA, 2007: 6). Error can occur at any stage of medication process which includes prescribing, dispensing, administering and monitoring.
Senior pharmacist of the Medication
Safety Team D. Gerett revealed number of medication errors reported in 2014 which is 41 000. Chief pharmacist of Lincolnshire Partnership NHS Foundation Trust S. Haider said that numerically it is a small problem because in his work area there is only 0,4 % error rate (1 in 250 medication tasks). He suggests that it is more important to focus on harm not on rate (Robertson 2015).
Types of medication errors can be human errors, faulty system errors and environmental errors.
Factors of human errors include poor knowledge of medication or poor experience, lack of effective communication, misinterpretation of drug package information or unclear prescription. However environmental factors such as distractions, poor light on night shifts, noisy and busy ward can have an impact and increase the risk of personal errors occurrence. Poor management and teamwork, lack of staff, unclear error report process, poor training and research resources can lead to organisational or faulty system errors. Also it create additional pressure and can increase medication errors risk. All of these causes are related to each
other. Literature suggests many ways to better practice. Double checking of dose by second registered professional independently could ensure that the right dose of drug will be administered and in that way reduce the risk of medication error occurrence. Another method is protected time during medication administration. It can reduce human and environmental errors, especially distractions. British Journal of Nursing suggests that 94% of nurses admitted that distractions in workplace has very big impact on medication errors factors. 88% of these distractions are interruptions from patients. Nurses can improve their performance and reduce human factors in medication errors by keeping their skills up to date. They need to know therapeutic uses of medication, side effects, allergies and contraindications. But safe medication administration is not only nurses responsibility. The NPSA(2007) statistics shows that 71 % of incidents are due: Unclear prescriptions The wrong dose being written The wrong frequency being prescribed The drug being omitted The medicine being delayed.
These factors are very often out of nurses control and shows that doctors, pharmacists and other healthcare professionals are also responsible for safe medication administration and have very big impact on medication errors factors.
Studies showed that 39% of medication errors occurred in doctors prescribing stage (Agyemang and While 2010). Design,packaging and labeling sometimes can also mislead and contribute to error. All members of team should work together to ensure safe practice. (S.Edwards and S. Axe) 'Patient safety is dependent on the skills, attitudes and actions of healthcare professionals, and also the systems and processes in place to support their work. Medical error is rarely caused by bad individuals. More often it is the end result of bad systems' (NPSA 2010).
Swiss cheese model was mentioned in 'Nurse prescribing' (2015) and very well illustrates relation between prescribing and administrating in whole drug journey to the patient. 'The holes in the slices of Swiss cheese represent a minor error. The holes may allow a problem to pass through to the next layer, but it can be stopped if the holes in the next layer of cheese are in different places.The more minor errors there are, the greater the likelihood of a major
error getting through. However, each layer, is a defence against an error becoming realised and affecting the outcome' (Edwards and Axe 2015, pp.398-399).
To prevent medication errors nurses are encouraged to follow five 'R's of safe drug administration. These are: right patient, right dose, right time, right route and right drug. S. Edwards and S. Axe have introduced five new 'R's because first five 'R's fail to consider other factors which can occur in more complex settings. In some cases patient can refuse to take medication or have a difficulty in taking medication. That's why sixth right was implied: the right to refuse the drug. Also it can give a right to nurse to refuse to administer medication (e.g. prescription is incorrect). The seventh 'R' is right knowledge and understanding. This knowledge is about side effects, interactions, toxicity, naming of the drug, how drug can affect body, how to prepare and store medication. The eighth 'R' is: right questions being asked. It involves considering if medication being given for the right reason, is formulation best suitable for the patient, is prescription correct, is it given to treat side effects of other medication. The ninth 'R' is right advice and it suggest that health professionals should be able to provide patient with information about possible side effects, effectiveness, the importance of taking the medicine and how it works, interactions with other medicines. By providing this information to patient health professionals contribute to therapeutic relationship between the clinician and patient. The tenth 'R' is right response or outcome. It involves considering if the outcome of treatment is as expected, has the patient experienced any side effects, allergies or adverse reactions. It also includes documentation of patient’s response to medicine and notifying relevant parties if any allergy, interaction or side effect occur. Side -effects or adverse reactions are often predictable. However, reactions to them can not be predictable and can have very serious impact on health. Adverse reactions have been identified as unintended harm or complications but potentially preventable. 'Medication errors are the most frequent cause of hospital adverse events and occur when personal and organizational factors interact with the medication process to produce an unintended and potentially harmful outcome' (Agyemang and While 2010, p.384).
Inappropriate use of drug can contribute to adverse reactions. 22% respondents of ADE survey reported having experienced an ADE in the past year. 51% respondents received at least one potentially inappropriate medication (Chrischilles et al. 2009).
NHS suggests to report side effects by using Yellow Card Scheme. Patients can access it online, call freephone hotline or pick up Yellow Card form from their GP. By being involved and reporting side effects patients can help to ensure the use of medicine will be reviewed and actions are taken to make it safer in the future (NHS 2015).
NPSA aims to reduce risks to patients and 2001 was established to analyze information about adverse reactions and ensure that lessons were learnt by providing feedback to organisations.
Any medication incident should be reported to NPSA .Sometimes health care providers trying to conceal their mistakes. But reporting mistakes can be equivalent to prevention. Failings to report medication errors or contraindications and side effects can give a misleading insight to the real picture and can lead to failure in improvement of medication safety. If health care agencies have the right statistics they can evaluate causes and create better risk management or prevention plan. Koohestani and Baghcheghi suggests that fear is primary individual barrier in reporting incidents among nurses. Other barriers to reporting included: motivational factors (e.g. fear of loss of professional registration), the process of reporting, perception that nothing will be done anyway, not being aware about error. Climate of organisation also has an impact of likelihood of reporting medication errors. Mistake is always something embarrassing, devastating and it affects both patient and professional who made a mistake. It is obvious that patient is a victim and can suffer physical and physical and consequences. Patient who experienced medication error can feel fear and danger to his health, fear of long term consequences, can be angry and disappointed with treatment, lost trust in medical staff, blame nurses or hospital. Also patient's relatives can experience many negative emotions and be worried about their loved ones. But nurses also suffer from negative feelings of guilt, fear and loss of confidence. It affects personal and professional life especially if they have to face criticism or disciplinary action. Some of them not able to continue their profession and if they continue to practise, they constantly having a fear of making another mistake.
Children and patients with known allergies are particularly vulnerable to medication errors.

Conclusion: medicine is always given with good intention and patient’s safety remains high priority. Even if all possible actions have been taken to prevent patient from harm, as with any intervention risks still can occur. To protect patients from harm is not only nurse’s responsibility but by considering all 10 ‘R’s nurses can recognise mistake in it’s final stage. Medications journey to the patient has many stages and the last stage of process is medication administration this is why is very important to follow safe drug administration instructions. All the factors of medication errors are known, however sometimes many of them are out of nurses control.