Medication Errors Analysis in Health Care Facilities Report (Assessment)

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Introduction

Access to quality healthcare services is an important goal of every citizen. A medication error, on the other hand, reduces the efficiency of such services and could lead to fatal consequences. Ghalibi et al. (2020) define a medication error as an avoidable incident that may contribute to inappropriate medicinal usage or harm patients when the prescription is in the hands of the healthcare provider or consumer. Unfortunately, inadvertent medication errors and unreported prescription errors lead to considerable morbidity and mortality (Bradley et al., 2017). This paper aims to analyze the consequences of medication errors and give solutions to how these errors can be redressed.

Elements of the issue

Medication errors can occur due to human error, but they typically tend to result from a defective process with insufficient redundancy procedure to identify mistakes. Research has shown that individuals seeking medical care are prone to medication errors because of the availability of a dozen prescription pharmaceuticals and innumerable over-the-counter treatments (Hassen et al., 2018). The presence of health supplements like herbs and lotions and the wide range of medicinal varieties also poses a risk of medication errors. These factors contribute to errors such as confusion resulting from similarly titled or packaged drugs and errors in the amount of prescription that lead to overdosage or under dosage. Illegible writing of prescriptions, distractions from the busy schedules of health providers, and lack of effective communication in making medicine requests also contribute to medication errors.

For ages, physicians have struggled with illegible handwriting as they are usually rushed and jot orders that are not readable, frequently leading to serious drug errors. Taking shortcuts when creating drug prescriptions is a sure-fire way to end yourself in court. Occasionally, the pharmacist cannot comprehend the prescription and must make an educated estimate. The patient is at even greater risk if the medicine is needed in an emergency.

Recently, numerous new drugs have been released, and generic versions with identical names have crowded the industry. Most of these drugs have various applications and alternate names in addition to possessing similar names. This has created a lot of confusion, especially in cases where the drugs possess similar names but are not used for the same purpose. In cases where the pharmacist or physician is to select such a drug from a drop-down menu, it is not uncommon to select the wrong name of the drug.

In health facilities, physicians are tasked with handling drug prescriptions in addition to examining patients, assessing laboratory results, speaking with consultants, and addressing the patient family members, among others. Distractions are a leading cause of drug mistakes as they result in close to 75% of pharmaceutical mistakes (Scherbak et al., 2020). In an attempt to complete all these tasks, a slip in judgment can occur, resulting in a pharmaceutical mistake.

Analysis

As medical health personnel, I must acknowledge the presence of medication errors and the factors that contribute to these errors. It is also important that I recognize the harm that such errors may cause to a patient and the health care ecosystem in general. The first step in solving a problem is acknowledging that it exists (Getzels & Csikszentmihalyi, 2017). In this case, medication errors have been reported severally in the past decade, and this creates a need to find the root cause of the problem and try to remedy it to attain more efficient health care systems.

The context for patient medication errors

With the complexity of health care systems, there is a possibility for medication errors as health personnel is tasked with so many processes that they strive to handle. The increase in drug variations in the market and their generic versions with identical names have crowded the industry and further added to the medication error concern (Scherbak et al., 2020). This is a recipe for confusion as the identical names can easily be confused from a drop-down menu. The other major contributor to a medication error is human inefficiency, for example, illegible handwriting and unclear prescriptions, which result in pharmacists making assumptions about the intended meaning and often administering wrong drugs to patients. All these factors keep adding to the medication error concern and therefore need to be addressed.

Populations Affected by Patient Safety Issues

Anybody who needs access to medication runs the risk of experiencing medication errors. However, certain people like children below five years of age, the elderly, and individuals with poor health literacy are at a higher risk of falling victim to medication error. Children below five years of age are particularly at risk because the dosage amounts may not be adjusted to cater to their needs. Poor handwriting further puts more risks to people with poor health literacy since they cannot comprehend the contents of the prescription.

Considering Options

To remedy medication errors that have fatal repercussions, health care personnel needs to pay keen attention to prescriptions and drug administration. They should never presume that the other person understands what they are talking about when writing medicine prescriptions. The prescriptions ought to include detailed directions on dosages, pill counts, and the frequency of taking the drug (Scherbak et al., 2020). It is a recipe for disaster to write directions like “take as ordered.”

Health facilities need to devise guidelines that physicians and pharmacists should adhere to. For instance, if a prescription is unreadable, the physician must be contacted and instructed to rewrite it. In this light, the pharmacist should never assume what the prescription or dose is. This could lead to a misunderstanding and administration of the wrong dose or type of drug. The guidelines should include a standard format that contains details like the diagnosis, type of drug prescribed, and amount to be taken.

With the rise in technology adoption, it would be even more efficient if health facilities adopt information systems that aim at eliminating handwritten prescriptions. These computerized systems could also prevent miscommunications as they can implement unique codes for each type of drug and help prevent the errors associated with picking the wrong type of drug from a drop-down menu. Also, the systems could implement a standard format whereby, for a prescription to be sent to the pharmacy or printed, all fields that contain the type of drug, amount, and diagnosis should be filled.

Solution

Due to the high traffic of activities in a health care setting, common mistakes are bound to happen, and these are prevalent in drug prescriptions. This calls for the adoption of more efficient processes of operating that could help the health care personnel to manage these problems. An E-prescription is described as the use of electronic software to generate, transmit, and file a prescription as opposed to the use of paper or faxed prescriptions (Ueyama et al., 2021). This management software could help streamline challenges that come with misinterpretations by pharmacists and illegible handwriting of the physicians.

An E-prescription software, however, runs the risk of malfunction and breakdown. This creates an ethical concern regarding the integrity, availability, and confidentiality of patients’ records. A backup system for the E-prescription should be put in place, and the system should provide an option of confirming patients’ details before submitting. Also, it should enforce security measures to ensure the confidentiality of patients’ records and prevent unethical lawsuits of data breaches.

Implementing the solution

An E-prescription software that aids in the efficient communication between physicians and pharmacists should be implemented. The system should enforce the three principles of data availability, confidentiality, and integrity. In availability, regular backups of the data and the system should be performed by the authorized personnel. In integrity, the system should allow confirmation of patients’ records before submitting them. Confidentiality being the guiding principle in a health care environment, should be ensured by only granting access to the records by authorized personnel. This could be implemented by requesting passwords and other login credentials before accessing patient records.

Conclusion

Medication errors have remained a source of worry for healthcare providers around the world. Research shows that these errors result from human inefficiency, but they typically tend to be the result of a defective process with insufficient redundancy procedure to identify mistakes. To remedy these errors, an E-prescription information system needs to be implemented in healthcare facilities to aid in effective and efficient communication between healthcare personnel in regard to patients’ diagnoses and prescriptions. If put in place, the system will ensure data confidentiality, data availability, and the integrity of patients’ data. It will also save the facilities time and costs associated with medication errors.

References

Aseeri, M., Banasser, G., Baduhduh, O., Baksh, S., & Ghalibi, N. (2020). . Pharmacy, 8(2), 69. Web.

Garcia, R. D., Zutião, G. A., Ramachandran, G., & Ueyama, J. (2021). Towards a decentralized e-prescription system using smart contracts. In 2021 IEEE 34th International Symposium on Computer-Based Medical Systems (CBMS) (pp. 556-561). IEEE. Web.

Getzels, J. W., & Csikszentmihalyi, M. (2017). From problem-solving to problem finding. In Perspectives in creativity (pp. 90-116). Routledge.

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). The proportion of medication error reporting and associated factors among nurses: A cross-sectional study. BMC nursing, 17(1), 1-8. Web.

Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet].

Walsh, E. K., Hansen, C. R., Sahm, L. J., Kearney, P. M., Doherty, E., & Bradley, C. P. (2017). Economic impact of medication error: a systematic review. Pharmacoepidemiology and drug safety, 26(5), 481-497. Web.

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