Introduction
Medications or medical items are designed to be taken in by or provided to a person or animal for a variety of purposes, such as disease prevention or diagnostics, among others. These substances are known to have biological effects and are pollutants. The product’s active ingredient is typically a medication, a prodrug, or a cellular component.
The act of administering a medication (the object) to a patient for any purpose is referred to as the medication process. A medication error happens when the patient suffers injury as a result of the treatment process failing, or it has the potential to cause harm to the patient. A medication error refers to the unfavorable side effect that occurs when a patient takes the incorrect drug or dosage, regardless of how obvious or severe the side effect may be.
Elements of a Medication Error
It takes a sophisticated process for a medical professional to administer medication therapy to a patient. From the initial prescription to the final delivery of the medication to the patient, mistakes can occur at any point in the process, whether intentional or unintentional. Dispensing errors related to the pharmacy or the healthcare provider delivering the drug are among the most common errors of commission. They can mostly be brought on by delivering the wrong medication, dosage form, or strength, miscalculating the dose, or failing to recognize drug interactions or contraindications.
Analysis of Medication Errors
Due to its serious effects on patient care and outcomes, medication mistakes are a subject that is frequently debated in the healthcare industry. While some have attributed the errors to systemic problems, others have highlighted specific patient populations that may be more susceptible to medical mistakes than others. In certain circumstances, it may be challenging to determine the precise cause of a medical error. However, it is still crucial to consider mitigation and prevention techniques to stop these unfavorable events from happening in the first place.
By developing a framework for quality improvement, root cause analysis (RCA) has been previously shown to reduce clinical and surgical errors across various disciplines. RCA stands for the method of determining the causes of performance variances. A standardized RCA process helps determine the root cause of medical mistakes, enabling healthcare organizations to create plans to prevent similar mistakes in the future by identifying flaws in system-level operations that can be redesigned to protect patients and reduce the likelihood of similar sentinel events.
Take a patient who has been identified as having severe preeclampsia as an example. To stop an impending seizure, the senior obstetric resident prescribes a loading dose of magnesium sulfate. The patient receives a 4-gram (20% concentration) intravenous solution bolus and a 10-gram (50% concentration) intramuscular injection, which is administered as 5 grams in each buttock, according to the hospital’s protocol. The junior fellow receives the order for the administration of magnesium sulfate verbally from the senior resident, who then verbally relays the order to the nurse.
The nurse is pressed in the urgent circumstance and mistakenly prepares this complex magnesium sulfate dosing regimen, which has many doses in various locations. The medicine preparation area features a chart that shows how magnesium sulfate is made, but it is faded. Because of this, the nurse prepares the medication from memory, which results in incorrect dosage. As a result, the pharmaceutical communication procedure can be immediately linked to the error.
Potential Solutions to the Problem of Medication Errors
Promoting public safety requires constant attention to dispensing accuracy, the integrity of the transmission of prescription and medication orders, and ongoing evaluation and improvement of pharmacy operating systems. To lessen the likelihood of a medication error occurring, further actions might be put in place. Educating patients appropriately about how to utilize their medications is one such strategy.
With the right information, patients can take an active role in their care and avoid mistakes. Patients themselves bear some of the responsibility for preventing medical errors in addition to healthcare professionals and systems. Patients can serve as the system’s last line of defense by being informed not only about the names of their medications but also about the reasons for taking them, the proper dosage, and the times they should be taken.
Enhancing the reporting process is the alternative remedy if a drug error is discovered. Medication errors must be addressed through process improvement initiatives in order to truly improve patient safety, despite the fact that they are considerably more difficult to detect with systematic reporting techniques. The monitoring of pharmaceutical errors is improved by lobbying and regulatory efforts. As an alternative, prior authorization procedures can be used to help manage healthcare systems and provide high-quality, affordable prescription drug benefits. Prior authorization procedures play a crucial role in enhancing patient safety by encouraging prudent drug usage.
A number of technology solutions are also available to aid with the issue. The electronic prescription record (EPR), which includes all the information legally necessary to fill, label, dispense, and/or submit a payment request for a prescription, is one such technology. Pharmacists can use the data to prevent drug interactions, double therapy, and drug contraindications, which will help to lower medication errors.
Pharmacists can use the EPR to do potential online drug use reviews (DUR). When a prescription order is provided for filling online, the DUR procedure enables the pharmacist to analyze it and proactively address any potential drug-patient issues. The alternative option is to employ bar codes, which are common machine-readable tags that can be used to help verify that the correct drug and dose are given to the correct patient. Even the smallest containers now have scannable bar codes that contain a growing amount of data, thanks to modern technology.
Chosen Solution
Since it enables prescribers to electronically transmit patients’ prescription information to pharmacy computers, the EPR is the solution of choice. This procedure results in fewer prescriptions and drug errors, as well as fewer calls from pharmacies to doctors asking for clarification. Prescriptions can be electronically sent and received, which can improve compliance, patient happiness, and the workflow of professional practices. EPR lowers paperwork and the errors that could result from relying solely on handwritten notes, as it connects physician and pharmacy systems, which also saves time and money for all parties.
Ethical Implications
Medication mistakes are rarely the result of carelessness or incompetence on the part of medical staff. Instead, they often arise as a result of a failure in the procedures that govern patient care. There are four basic ethical principles that can be used to group the key ethical concerns with drug errors. The first are the principles of beneficence and non-maleficence, which usually tell healthcare professionals to act in patients’ best interests and prevent harm. When weighing the patient’s potential risks and benefits, this could lead to ethical dilemmas for healthcare professionals, so they should take the appropriate precautions to reduce the damage a mistake might cause.
The others include autonomy and right to self-determination, which acknowledge patients’ rights to make individual choices. The next principle of veracity requires healthcare personnel to provide comprehensive, accurate, and objective information in a manner that helps patients understand the information. Lastly, healthcare providers have an ethical obligation to disclose information that patients need for informed decision-making.
Implementation
The EPR can help decrease pharmaceutical errors by assisting pharmacists in monitoring and auditing usage. Additionally, it can help with provider communication to enhance patient care. When managed health care systems eventually connect the EPR to other medical record systems, prescribers will be able to send prescriptions straight to the pharmacy of the patient’s choice. Through a process of whole patient management, including the elimination of medication errors, this integration of the patient’s entire pharmacy and medical record will improve care.
Conclusion
Medication errors occur due to failures in the process of prescribing drugs to patients. Mistakes, which can be intentional or unintentional, can happen at any point in the process. RCA can be used to analyze the problem, as it has previously helped to lower clinical and surgical errors in a variety of disciplines, when applied to determine the causes of performance variances.
Several solutions can be applied to contain the problem, including educating patients, enhancing the reporting process, and using technology tools, such as EPR, barcodes, and DUR. EPR is the preferred solution due to the electronic link between the prescriber and the pharmacy. Ethical issues that can affect the solution include beneficence and non-maleficence, autonomy, right to self-determination, and veracity.
References
Ben Tore Henriksen, Krogseth, M., Randi Dovland Andersen, Maren Nordsveen Davies, Caroline Thy Nguyen, Mathiesen, L., & Andersson, Y. (2023). Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: A nonrandomised controlled trial. Journal of Orthopaedic Surgery and Research, 18(1).
Chiruvella, V., & Guddati, A. K. (2021). Ethical Issues in patient data ownership. Interactive Journal of Medical Research, 10(2), e22269.
Savva, G., Papastavrou, E., Charalambous, A., Vryonides, S., & Merkouris, A. (2022). Exploring Nurses’ Perceptions of Medication Error Risk Factors: Findings from a Sequential Qualitative Study. Global Qualitative Nursing Research, 9.
Suzuki, R., Sakai, T., Kato, M., Takahashi, M., Inukai, A., & Ohtsu, F. (2022). Analysis of medication and prescription background risk factors contributing to oral medication administration errors by nurses: A case–control study. Medicine, 101(33), e30122.