This paper reviews medication errors from the perspective of the healthcare system. An overview of medication errors is provided, including the effect that medication errors have on the healthcare systems as a whole. Methods for reducing medication errors are provided among healthcare professionals individually and as a group.
Medication Errors: A Systems Approach to Healing
Medication errors cause thousands of deaths each year, requiring strict attention to protocols and systems review. As a result many healthcare facilities are looking at their policies, procedures and systems to determine methods for reducing medication errors among personnel and as an organizational entity.
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"Medication Administration: Medication Errors".
According to Kass (2013) adverse drug events, also known as ADEs cause more than 770,000 injuries and deaths every year. The same ADEs cost nearly $5.6 million dollars in the hospital setting contingent on the size of the healthcare facilities (Cullen, Sweitzer, Bates et al., 1997). If hospitals were to make changes to their systems to prevent and detect ADEs, then mortalities and injuries could be reduced. Thomas, Studdert, Burstin et al (2000) note medication errors and ADEs can result from multiple factors including interactions among healthcare practitioners, patients and various uses of medications. The resultant costs are very high, including fatality or permanent disability. Computerized systems can help reduce the risk of medication errors by assisting healthcare practitioners in monitoring patients, providing assistance with tracking order entry, and by integrating information related to patients, pharmacy and laboratory results and data (Kass, 2013). Further, computerized systems can aid in tracking the number of ADEs, so that methods can be developed for reducing the incidence of errors by determining the root cause of such errors.
Computer systems are one part of the medication error solution. Other studies suggest that programs that can assist in reducing errors include improving reporting of errors, to streamline healthcare providers scheduling with a process to improve feedback on reporting and the results of or consequences of medication errors (Kass, 2013). Further, there is a program available via the FDA, MedWatch that allows patients and healthcare providers to report adverse drug reactions (Kass, 2013). This program can provide for labeling changes or result in the withdrawal of a medication from the market in situations where a drug is deemed dangerous or has caused significant harm to a patient or others.
By providing a better environment where healthcare providers work and report ADEs, and where individuals working in the healthcare environment have no fear of punishment for reporting ADEs, there is more chance for accurate reporting and help for patients (Kass, 2013). This is critical to the success of a program committed to the resolution of medication errors. Punishment prevents deterrence from reporting, but reporting is critical for resolving critical medication errors. Thus, while it may be frightening to admit errors, it is also essential for healthcare personnel to do so, so that errors may be discovered and resolved in a timely fashion. Further, healthcare providers including physicians and pharmacists may take more control over providing education and prescription control over medications, to reduce the odds of medication error resulting from nurse delivery or prescribing power over medications (Kass, 2013).
Studies from Brigham and Women’s Hospital suggest that the ADE rate in the ICU was reduced from 33 for every 1000 patients to under 12 per 1000 patients by utilizing pharmacists during administration f patient medications during patient rounds rather than having nurses administer medications during patient rounds (Kass, 2013). This suggests that costs could be dramatically lowered associated with medication errors by having a qualified pharmacist prescribe and administer medications. Further, providing additional training in medication administration and monitoring could alleviate the burden associated with medication administration and error. Changes may include training in documenting medication errors, coding medication, and training the potential harm of certain prescription medications, including harm associated with medications that are frequently associated with harm.
- Cullen, D.J., Sweitzer, B.J., Bates, D.W. Et al. (1997). Preventable Adverse Drug Events in
Hospitalized Patients: A Comparative Study of Intensive Care and General Care Units. Crit Care Med, 25(8): 1289-97. - Kass, B. (2013). Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs.
Research in Action, (1): Publication 01-0020. Agency for Healthcare Research and Quality, U.S. Department for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html - Thomas, E.J., Studdert, D.M., Burstin, H.R. et al. (2000). Incidence and Types of Adverse
Events and Negligent Care in Utah CO. Med Care. 38(3): 261-71.
