A medication error refers to any avoidable occurrence that has the potential to result in improper use of medication or harm to the patient, occurring
while the medication is under the supervision or responsibility of a healthcare provider, patient, or consumer (Carver et al., 2019).
- In the previous six months, 2 million Australians encountered an adverse medication event.
- During medicine reviews, over 95% of residents in assisted living facilities had at least one medication-related issue found; the majority had three (Kalisch et al., 2023). Between 40 and 50 percent of elderly residents take medications that have the potential to be sedative or confusing.
- Anticholinergic medications are taken by 50% of dementia patients,which can worsen confusion and other dementia symptoms (Coupland et al., 2019).
- Every year, medical issues cause 72,500 Australians living in rural and remote areas to be admitted to hospitals (PSA, 2021).
Healthcare professionals such as doctors, nurses, pharmacists, and
sometimes even administrative staff who may be responsible for record-keeping or medication administration (Abdulmutalib & Safwat, 2020).
- Hospitals (especially busy departments; 0.3% to 9.1% in prescriptions) (WHO, 2022).
- Long-term care facilities (nursing homes, assisted living)
- Ambulatory care clinics (primary care, specialty clinics)
- Pharmacies (from 1.6% to 2.1% at the dispensing stage) (WHO, 2022).
- Home healthcare (self-administration)
- Mental health facilities (complex psychiatric medications)
- Pediatric settings (dosing complexity for children) (Blaine et al., 2020)
- Rehabilitation centers (complex medical histories)
- High workload and shift changes increase risk (Schroers et al., 2020).
- Fatigue and time pressure contribute to errors (Schroers et al., 2020).
- High-stress areas like ED and ICU have higher risks (Ottosen & Bucknall, 2023).
Globally, medication errors have an estimated annual cost of $42 billion USD (WHO, 2023). 237 million medication errors per year. Out of these, 66 million have potential clinical significance (Elliott et al., 2021).
Medicine-related problems lead to 250,000 hospital admissions annually (Lim et al., 2022). Over half of these admissions are considered preventable.
Medication errors lead to primary care adverse drug events causing hospital admissions (£83.7 million in costs; 627 deaths) (WHO, 2022). Additionally, secondary care adverse drug events lead to longer hospital stays (£14.8 million in costs; 1081 deaths). (WHO, 2022).
Medication errors can occur at various stages in the medication use process Prescribing Errors: These occur when a healthcare provider orders the wrong medication, dosage, frequency, or route Error rates for medication prescription orders range from 5% to 11% (Roughead et al., 2013). For example, a physician might prescribe 100mg instead of the intended 10mg of a medication.
Dispensing Errors: These occur when a pharmacist provides the wrong medication or dosage to the patient. This could happen due to a misinterpretation of the prescription or a mix-up with a similarly named medication. In Australia, about 792,000 prescriptions are provided daily through the Pharmaceutical Benefit Scheme (PBS) and Repatriation Schedule of Pharmaceutical Benefits Scheme (RPBS). Even a 1% error in dispensing could have severe (Poole et al., 2021) Administration Errors: These occur when a healthcare provider administers the medication incorrectly. For example, a nurse might give a medication meant for oral administration intravenously. Errors in medication administration happen at a frequency ranging from 5% to 18% (ACSQHC, 2020)
Monitoring Errors: These occur when the patient's response to medication is not adequately assessed or documented. For instance, a nurse may fail to monitor a patient's blood pressure after administering a medication known to affect it. In public hospitals, improper monitoring accounted for 6.6% of adverse events, whereas in private hospitals, it was 3.8% (AIHW, 2018). Patient Adherence Issues: These occur when the patient fails to take the medication as prescribed, which can lead to suboptimal treatment outcomes or exacerbation of the condition (Kvarnström et al., 2021). For example- Medicines that are to be taken with food if not can result in nausea.
Types of Medication Errors Wrong Medication: Giving the patient a different medication than the one prescribed. Example: Prescribing Zantac but giving Zyrtec due to similarsounding names. Wrong Dosage: Administering a dosage significantly different from what was prescribed. Example: Prescribing 20mg but giving 200mg, potentially leading to overdose. Wrong Route: Administering a medication through an incorrect method, such as giving an intravenous medication orally. This can reduce efficacy or cause adverse effects. Wrong Frequency: Patient takes a medication more or less frequently than prescribed. Example: Taking a once-daily medication twice daily, potentially increasing risk of side effects. (Hanson & Haddad, 2022) Drug-Drug Interactions: Combining medications that have a negative interaction, potentially leading to adverse effects. Example: Combining a blood thinner with an NSAID, increasing risk of bleeding (Al-Azayzih et al., 2020).
Fatigue and staffing levels causing lapses in attention and concentration (Di Muzio et al., 2019). Lack of proper communication among healthcare providers, or between providers and patients (Tiwary et al., 2019). Inadequate training or education about medications, including proper dosing and administration techniques (Tariq & Scherbak, 2023). Lack of access to patient information especially regarding allergies, current medications, and medical history (Tariq & Scherbak, 2023). Electronic Health Record (EHR) Errors lead to incorrect dosage calculations, prescription entry, or administration records (Gates et al., 2020). Distractions and Interruptions in busy environments (Alteren et al., 2021). Over-reliance on memory for medication dosages or administration schedules (Taft et al., 2023)
Short term impact Adverse Reactions and Side Effects Hospitalisation or Extended Stay Immediate Health Deterioration Psychological Distress Family Distress (Phuong et al., 2019; Rodziewicz & Hipskind, 2020).
Long-term Impact Chronic Health Issues Decreased Quality of Life Increased Healthcare Costs Emotional Impact on Families Legal and Regulatory (Rodziewicz et al., 2023; Rasool et al., 2020) Consequences
Risk to registration and licensure Legal consequences and liability (Shore et al., 2021)
Employment consequences such as reassignment, suspension, or termination. Impact on professional reputation and potentially hinder future employment opportunities (Levine et al., 2019)
Impact Intense feelings of guilt and shame for making a medication error (Mahat et al., 2022) Heightened anxiety and stress, especially when administering medications in the future (Mahat et al., 2022) A loss of confidence in their clinical abilities and may doubt their competence as a nurse Strained relationships and social isolation (Athanasakis, 2019)
Medication Reconciliation: Conducting a thorough review and comparison of a patient's current medications with newly prescribed medications. This helps identify any
discrepancies, such as omissions or duplications, reducing the risk of medication errors during transitions of care (ACSQHC, 2023).
Utilizing Barcode Medication Administration (BCMA) Systems: Scanning barcodes on patient wristbands and medication labels before administering medications. BCMA systems
help verify that the right medication is given to the right patient at the right time, reducing the risk of administration errors (Mulac et al., 2021).
Double-Checking Medications: Prior to administration, independently verifying the medication, dosage, route, and patient's identity. This serves as an additional layer of safety to
catch any discrepancies or potential errors before they reach the patient. It's a crucial step in ensuring accuracy (Chua et al., 2019).
Using Technology for Decision Support: Employing electronic health record systems with clinical decision support tools for medication prescribing and administration.These
systems provide real-time alerts and guidance on dosages, potential drug interactions, and allergy warnings, helping to prevent errors at the point of care (Shahmoradi et al.,
2021).
Effective Communication and Collaboration: Ensuring clear, open, and respectful communication with other healthcare team members, including physicians, pharmacists, and
other nurses. It reduces the likelihood of misunderstandings and misinterpretations, which can lead to medication errors. It promotes a culture of safety and encourages
collaborative problem-solving (Rodziewicz, & Hipskind, 2020)
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