Running Head: MEDICATION ERRORS 1

Executive Summary- Medication Errors

Kathryn Forsyth

Capella University

HealthCare Quality Safety Management

July, 2020

Proprietary

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MEDICATION ERRORS 2

Executive Summary- Medication Errors

Medication administration continues to be an issue, from start to finish, errors can occur.

The bedside nurse if responsible for about a quarter of medicine errors as they happen during the

administration phase (Armstrong et al, 2017). Medication administration is a multistep process

that requires clinical judgements, professional care, and analytical thinking. Medication

administration often happen is a busy environment, nurses must be able to manage multitasking

while upholding patient safety and clinical skill (Armstrong et al, 2017). Currently medication

errors are under reported, researched, and recognized and this needs to be addressed.

A Quality Interagency Coordination Task Force was created by the Department of Health

and Human Services and other federal agencies has advised using teamwork is an important way

to improve patient safety (Buljac-Samardzic, Dekker-van Doorn, & Maynard, 2018). Factors to

address when developing a plan to reduce medication errors include increasing reporting without

punishment, when and where did the error occur, and how many changes did the staff have to

prevent the error. Creating quality initiatives, improvement strategies, new policies and

procedures are ways to decrease medication errors. Administration and leadership should use

each near miss and adverse event as a teaching opportunity with the staff and determine how the

error can be prevented in the future.

Many healthcare organizations have banded together to research ways to decrease

medication errors. Nurse education is an ongoing process as there are new medications with look

alike, sound alike names. Understanding the cause of medication errors will improve the nurse’s

knowledge and provide nurses the ability to learn from mistakes. About 5% of medication

adverse events are related to a lack of nurse knowledge related to the medication (Patient Safety

Network, 2019). Nurses should always look up information on any drug they are unfamiliar with

and be encouraged to ask questions to try to reduce these events. Use of technology has also

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MEDICATION ERRORS 3

decrease medication errors by using the barcode to scan the patient arm band and the medication

to prevent errors by verifying the right patient is getting the right medication at the correct time

(Alotaibi & Federico, 2017). Adding healthcare technology has reduced the near miss and

adverse events however all healthcare staff must not rely in the technology and continue to use

their knowledge, double check system, and allow the computer to be the verification of the

information we have already verified.

Analyzing the Issue

Medication adverse events and near misses are costly to the facility and insurance

companies. Approximately 400,000 hospitalized patients per year experience some type of

preventable harm, with a result in approximately 100,000 people dying as a result each year.

These errors cost about $20 billion dollars per year which creates a financial burden, some errors

that cause death or cause long term effects can lead to legal risk that will only increase the

financial burden (Rodziewicz & Hipskind, 2020). Many agencies are blaming the system for

medication errors as the staff are required to work long hours, often interrupted with

administering medication, and having to multitask. By not blaming the person, more events can

be reported without fear of retaliation and policies and procedures can be updated as we always

learn from the mistakes we make.

The systemic issues is with drug packaging, “The American Food and Drug

Administration (FDA) estimated that 20% of medication errors may be attributed to confusing

packaging and poor labeling; others suggested even higher rates” (Larmené-Beld, Alting, &

Taxis, 2018, page 1). Many drugs have look alike labels, names, and packaging. The primary

labels on the medication containers is very important as administering the incorrect drug can

have serious consequences for the patient. There have been many measures suggested to enhance

the improvement of being able to read the of labels and reduce errors related to look-alike labels.

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MEDICATION ERRORS 4

Use of technology is one option that most hospitals have already implemented which is the a

closed-loop system with barcode technology. Another suggestion is the use of Tall Man lettering

and color-coding which aims to highlight the difference between two similar drugs by

capitalizing part of the drug names. Many organizations have endorsed Tall Man lettering

including the Joint Commission and the Institute for Safe Medication Practices (ISMP)

(Larmené-Beld, Alting, & Taxis, 2018). Administration and leadership at our local hospitals are

encouraging nurses to report look alike, sound alike drugs to aid in the fight to get labels and

names changed to make it easier to differentiate between drugs.

The current unit we are evaluating is a 50 bed burn unit, statistics show in the past six

months there has been an increase in administering the wrong drug by 40%, right timeframe by

35%, and the wrong route by 16%. Nurses have attributed these errors to a few issues that

include distractions, lack of drug knowledge, and not enough information provided by the

prescriber. Medication errors is trending upwards on this unit and the plan is to address the need

for new interventions, education, and improving use of technology to reduce errors. This unit has

also had an influx of new graduate nurses which could be another reason for the increase in

errors.

Effects of ongoing medication errors include increase cost of healthcare, increased length

of stay related to adverse medication events, legal issues from events that lead to long term

complications or death. This causes a huge financial burden and reportedly costs up to $20

billion dollars per year (Rodziewicz & Hipskind, 2020).Most medication errors are preventable

and that is what this plan is addressing, ways to decrease harm to patients, improve patient

outcomes, decrease healthcare costs and try to prevent legal issues which increase overall cost to

the facility.

Safety Culture

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MEDICATION ERRORS 5

By creating a safe environment for reporting of medication errors, adverse events, and

near misses we are improving communication between everyone. As previously stated in this

paper, we can all learn from mistakes that we make or others make. A safe cultural is comprised

of several elements to include a just culture, engaged leadership, and complexity and improving

the of environment of care. Just culture understands that even the best, smartest individuals make

mistakes however there is no tolerance for behaviors that are repeated or violates policies and

procedures. People are not punished for making errors or voicing concerns but there is a clear

accountability principle. Engaged leadership as the force behind a safe culture. Leaders should

make safety part of the daily dialog and be addressed at each meeting. Leaders should encourage

staff to share concerns to allow a flow of information from staff to leaders and back. Leaders

should have clear expectations, support reporting of adverse events to patient and family and by

having a non-disciplinary response for those who self report or share concerns related to patient

safety. Understanding that healthcare is complex with many interdependent parts that can

continue to run even when someone goes to lunch, calls out, or the unit is short staffed. The unit

adapts to changes however sometimes a gap is left, which then causes nurses to alternate their

normal delivery of care, this increasing the risk for errors. An organization willing to discuss and

face problems is one way to identify emerging issues that could cause harm (Hemphill, 2015).

Best practice uses patient-centered quality initiatives focus on the analysis of the issues

and how best to become a High Reliability organization and obtain a Triple Aim framework.

Both address quality improvement initiatives to reduce possible patient injury and improve

patient safety. By using High Reliability and Triple Aim framework, we are seeing quality

interventions that improve patient outcomes, satisfaction, decrease mortality rates and

medication errors (Bodenheimer & Sinsky, 2014).

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MEDICATION ERRORS 6

Currently, the facility is using the bar code system which helps reduce medication errors

when used correctly, additional education is needed on correct use the scanner. The unit has

implemented the double check system with allowing the computer to be the triple check. We can

never replace nurse knowledge with computer as there are many things to take into consideration

when administering medications. Also, by increasing nursing education on pharmacology,

encouraging asking questions, self reporting without fear of punishment we learn the core reason

for the error to better create an initiative to prevent the error in the future. Currently the

multidisciplinary group is working on a standard way of reporting using the SBAR system

specifically for the burn unit however this could be modified to fit another unit needs as well.

Leadership has stepped up to provide support, an environment that encourages nurses to ask

questions, self-report errors, and voice any concerns. By working as a team, we will improve our

knowledge, procedures and decrease errors.

Leadership in a pivotal role in implementing quality improvement and keeping the team

engaged on the goal. Transformational leadership is a leader with a vision for the team who can

stimulate others in a clear and concise but also appreciative of the individual team members.

Transactional leaders influence their followers based on providing rewards for a job well done

and in response to their achieved defined goals (Saravo, Netzel, & Kiesewetter, J. 2017). Lack of

leadership can result in failure of implementing the initiatives, reaching objective, and not

meeting goals. Barriers may limit the nurse ability to provide quality patient care, these barriers

could be placed by leadership, management, administration, and other healthcare personnel

(Bodenheimer & Sinsky, 2014).

Outcomes measures will support the ongoing use of technology, triple check, increased

communication skills, standardized reporting by having a decrease in medication errors by ten

percent within the first month. This will be an ongoing process, so leaders will have to keep the

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MEDICATION ERRORS 7

staff motivated to incorporate the changes into their daily routines. Once habits are formed, we

expected medication errors to drop significantly withing 90 days.

Conclusion

Medication administration remains an area that constant quality improvements are needed

to decrease harm and improve patient outcomes. By using technology to create a system to verify

the right patient, right time and right dose medication errors have decreased. Creating a culture

of safety for staff to self report and express themselves, we are improving communication and

allowing others to learn from mistakes. This allows gives an opportunity to research why the

error occurred and create a plan to prevent the error in the future. Having strong leadership will

increase staff participation in interventions and will improve patient care and satisfaction.

Quality and safety of healthcare is a result of interventions, objectives, and goals to work

towards decreasing medication errors by all staff members. This will have a direct positive

impact on all stakeholders.

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MEDICATION ERRORS 8

References:

Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient

safety. Saudi medical journal, 38(12), 1173–1180.

https://doi.org/10.15537/smj.2017.12.20631

Armstrong, G., Dietrich, M., Norman, L., Barnsteiner, J. & Mion, L. (2017). Nurses' Perceived

Skills and Attitudes About Updated Safety Concepts. Journal of Nursing Care Quality,

32(3), 226–233. doi: 10.1097/NCQ.0000000000000226.

Bodenheimer, T and Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient

Requires Care of the Provider. The Annals of Family Medicine, 12 (6) 573-576; DOI:

https://doi.org/10.1370/afm.1713

Buljac-Samardzic, M., Dekker-van Doorn, C., & Maynard, M. T. (2018). Teamwork and

teamwork training in health care: An integration and a path forward. Group &

Organization Management, 43(3), 351-356. doi:10.1177/1059601118774669

Hemphill R. R. (2015). Medications and the Culture of Safety : Conference Title: At the

Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and

Medication Safety Venue ACMT Pre-Meeting Symposium, 2014 North American

Congress of Clinical Toxicology, New Orleans, LA. Journal of medical toxicology :

official journal of the American College of Medical Toxicology, 11(2), 253–256.

https://doi.org/10.1007/s13181-015-0474-z

Larmené-Beld, K.H.M., Alting, E.K. & Taxis, K. (2018). A systematic literature review on

strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol 74, 985–993.

https://doi.org/10.1007/s00228-018-2471-z

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Patient Safety Network (PSA). (2019). Medication Errors and Adverse Drug Events. Retrieved

from https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

Rodziewicz L., Hipskind J. (2020). Medical Error Prevention. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK499956/

Saravo, B., Netzel, J., & Kiesewetter, J. (2017). The need for strong clinical leaders –

transformational and transactional leadership as a framework for resident leadership

training. PLoS One, 12(8)

doi:http://dx.doi.org.library.capella.edu/10.1371/journal.pone.0183019

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