Introduction
Medication error is considered as a complex and complex issue in healthcare organizations involving any wrong medication prescribed to a client, incorrect dosage of a correct medicine, or any failure in communication during the prescription or administration of a drug. It is imperative to confront and minimize these errors on the grounds that it enhances the health situation of patients besides helping healthcare students in their professional experience. This NHS-FPX 4000 Assessment 2 will stress on eradicating medication errors, and will provide elaborative analysis of few chosen research articles as per their credibility. The assessment will consist of an annotated bibliography of four articles and brief discussion of the articles each of the articles will provide information about medication errors and possible ways of addressing them.
The implications of medication errors include complications, admissions to hospital or even death since medication is vital in the treatment of diseases. They can take place during the prescription process or during the medication administration. (Rodziewicz et al. , 2024) Potential causes include no cross-check mechanisms, increased staff congestion, staff shortage, inter-shift theme discrepancies, and poor or limited consultation with pharmacists as well as health care providers’ poor understanding. Aside from the effect on specific patients, medication errors also have further costs implications for the same patients and the health system as a whole damaging the reputation of health care facilities and serving as a problem in America’s healthcare sector. The U. S has measures including the use of the electronic healthcare systems and decentralizing of the pharmacists to curb these errors hence supporting the need to further address and prevent medication errors in a bid to improve the quality of healthcare being offered.
Medication mistakes are one of the significant issues within health care since they are dangerous to the lives of patients, as it is possible to administer the wrong concentration and the results will be disastrous. The aforementioned mistakes not only affect the well-being of the patients but also create a negative image of the healthcare workers, demoralize them as well as compromise the quality of service delivery in healthcare institutions. It transpired that the consequences of medication errors go beyond the patient level, which results in increased hospitalizations, patients’ distrust in their treatment and non-compliance to prescribed regimens. In this case, nurses and professional caregivers can suffer, and their adverse effects may entail financial losses, possible legal proceedings, or even license cancelation. Also, medication errors lead to increased duration of hospital stays, financial burden among the patients and institutions, high staff turnover due to health complications related to medication errors and this affects the image and efficiency of health facilities (Tariq & Scherbak, 2024).
Professional Experience
When working as registered nurse I witnessed medication administration error of which a junior nurse administered the wrong amount caused by a communication failure with the prescribing physician. However, the matter has been quickly rectified to avoid more negative impacts and it emphasized the importance of finding proper strategies of avoiding such mistakes in the future. Correcting medication errors involves an understanding of intervention measures that need to be put in place based on studies. The following annotated bibliography will go a long way in providing ideas on ways of preventing medication errors in favor of patient safety and the promotion of integrity in the delivery of health services.
It was therefore important to check the validity and suitability of literature to fit into this NHS-FPX 4000 Assessment 2. For the purpose of acquiring only the most pertinent data, Journal articles only were included in the sample and the search was done on articles within the last 5 years only. I searched PubMed and typed the keywords, medication safety, medication error, and adverse drug events. Besides, using the CRAAP test that assess the Currency, Relevance, Authority, Accuracy, and Purpose of the sources, I ensured that these sources were credible (Portillo et al. , 2021). It let me limit the choice of sources to only the most credible and useful ones, which made for a strong groundwork in responding to the problem of medication errors.
Identification of Peer-Reviewed Articles
When researching for medication errors and patient safety I had to use different databases like PubMed or search for peer-reviewed journals. Afaya et al. (2021) do an integrative review that comprises an understanding of the major challenges that hinder the reporting of MAEs among nurses; none of which a proper reporting system exists, and punitive measures against nurses exist. According to the study, institutions need to establish effective, non-retribution reporting system and effective educational interventions to enhance error reporting. From the identified articles, Alrabadi et al. (2021) targeted the role of medication errors in clinical contexts especially from the nurses’ standpoint, a requirement for equivalent standards all over the world and promotion of non-punitive approach toward errors.
Koyama et al.(2020) aim at assessing the impact of double-checking during administration of medications with emphasis on high risk medications on incidence of MAEs. All in all, the review studied 13 articles, however, the results were not conclusive: only one of the study, identified as of high quality, reported the decrease of the number of mistakes due to double check.
This goes to emphasize the need to get superior quality researches that are going to help to define if there are other pros of the practice other than the ones assumed. Lastly, Manias et al. (2020) synthesized a systematic review of the different interventions seek to decrease medication errors in acute medical and surgical wards. Based on their studies they have discovered that pharmacist led medication reconciliation and computerized physician order entry reduced prescribing and administration errors and found that patient safety needed multi-professional approach in healthcare.
Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1), 1–10. https://doi.org/10.1186/s12913-021-07187-5
This article reviews the literature on compliance with the reporting of MAEs among nurses, and the factors that may impede the process, at the organizational, professional, and behavioral levels. The review covers studies in the low, middle- and high-income countries, and thus the results are crucial to the global healthcare community in its attempts to enhance patient safety, which is an essential issue in many countries worldwide. The majority of the researched studies were considered to be of strong or moderate methodological quality, thus making it possible to draw sound conclusions that could be meaningful for the development of future nursing research and practice. This review supports the WHO’s `Global Patient Safety Challenge,’ which is to reduce moderate or major avoidable medication harming by 50% within the next 5 years. MAE reporting remains a focus within the study as behavioral change requirements which are core to the formulation of interventional approaches to improving patient safety outcomes are recommended.
Industry recommendations from clinical professionals are essential for policy-making, organizational, and stakeholder MAE reporting and for confronting challenges that hinder global patient safety.
The review reveals that organizational factors are the key potential sources of influence on the rate of reporting or under-reporting of MAEs by nurses. For instance, issues such as non-existent reporting systems, ambiguous definitions of MAEs and punishment of nurses after reporting incidences. Most healthcare facilities do not have effective reporting systems in place that protect nurses from recrimination when they report errors, thus allowing patient safety to remain a low priority. In order to overcome these challenges, the study suggests setting up reliable reporting systems that could provide sufficient information on MAEs’ occurrences. Also it recommends that there should be non-punitive measures that should be put in place to encourage error reporting to be put in place alongside; programs that would help to enrich knowledge on MAE reporting among nurses. The review also emphasizes the development of anonymous reporting systems for nurses as a protection against legal recourse and shifting towards a culture of reporting. Despite the above mentioned weaknesses such as geographical bias, and restriction to published articles in English, the study has implications that may guide policies to enhance patient safety through appropriate reporting of MAE.
Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025
In this NHS-FPX 4000 Assessment 2, medication errors (MEs) are considered to be one of the most dangerous types of medical errors in clinical practice as they influences different aspects of patients’ lives and describe the outcomes of physical, psychological, and financial losses. In the present case, the study affords knowledge of the topic and the authors also get to revisit the literature from the perspective of the nurses to improve on the delivery of health care services and performance on patient cares. This is particularity important for understanding and identification of errors and to promote patient safety, this is why the review is mainly centered on classification of MEs, their types, outcomes and the reporting.
The conclusions indicate the need for a general set of protocols to reduce medication errors although recognizing the fact that nurses are actively participating in the process of techniques to accomplish this. The corrective measures for the errors include Education and Training, Independent check on all activities, Standardization of operations and activities, Work culture that avoids blame apportionment and Improving on Communication and Documentation. Therefore the study suggests that, hospital administrators should support the error reporting culture, minimize interferences at the workplace and improve the job security of nurses to minimize risks in the health care sector.
Koyama, A. K., Maddox, C.-S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of Double Checking to Reduce Medication Administration errors: A Systematic Review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552
This systematic review assesses the impact of double checking in reducing MAEs and enhancing patient outcomes during medication administration in hospitals especially when implementing high-risk drugs. The review included 13 papers from five databases and included observational studies, antenatal RCTs, a postnatal RCT, and an online simulated trial. Incorporating studies was
done in a highly heterogeneous manner and these studies included pediatric as well as adult inpatients. Despite the positive relation that was established between double checking and a decrease in MAEs only one out of three of the high caliber studies revealed that double checking reduced MAEs but another study that was conducted didn’t find the link and the third studied only the compliance levels to the double-checking policy. Double checking was not studied on its ability to prevent medication-related harm and the rate of compliance of the double-checking policy ranged from 52% to 97%. In light of the above findings, the review posits that probable harm decrease and MAEs prevention benefits of double checking remain inconclusive. Additional challenges arise from variability of the studies’ designs, definitions of double-checking, and correspondence to the protocols of double checking. The study underscores the emergency of better quality research to establish the value of double checking in enhancing patients safety including cases of drug type and healthcare setting, and cost or resources available in establishing its pros and cons.
Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1), 1–29. https://doi.org/10.1177/2042098620968309
This systematic review therefore sought to compare the efficacy of different interventions in ACUTE areas of medicine and surgery in minimizing common medication errors in prescribing, dispensing and administration. The review comprised of 34 studies, of which 12 intervention types were determined. Meta-analysis of single interventions highlighted that single interventions like medication reconciliation performed by pharmacists, computerized medication reconciliation, and CPOE was useful in decreasing of prescription errors. In the same context, CPOE and automated
drug distribution systems proved efficiency in decreasing medication administration mistakes. Nevertheless, the eight studies carried out did not identify any measure that could be implemented to help decrease dispensing errors. The majority of investigation comprehensions occurred in a single institution as a vast majority of studies involved single-site hospitals. The review also pointed that few of the studies showed an ‘actual’ comparison with the patients who did not receive the therapies, and hence called for more rigorous study designs in the future.
A number of single and combined interventions are found feasible and effective in decreasing the prescriptions and the medicine administration mistakes in hospitals, and the findings of this review may be helpful for the clinicians and the policy makers. It stresses the significance of teamwork among doctors, pharmacists, and nurses to improve the patient safety even more. Future studies should, therefore, seek to identify ways of working in partnership and adopting control groups in order to improve the evidence base on these interventions.
Conclusion
This experience of compiling this annotated bibliography has been educational in perusing the persistent measures being taken toward mitigating medication errors which are dangerous threats to patient safety. In the following compilation, I have selected four articles from peer-reviewed journals which bring out the barriers and solutions regarding medication errors. These papers demonstrate the important factors in medication errors and the measures which need to be taken to minimize these factors that can cause adverse health effects and in some cases be fatal.
Afaya et al. (2021) have presented an integrative review that focuses on the major challenges that hinder the reporting of MAEs among the nurses as well as proposing the necessity of enhancing reporting systems and educating thinkers about error reporting. Alrabadi et al. (2021)
examined medication errors in clinical work settings with emphasis to the role of nurses, the need for structured approach and patient safety culture to implement mechanisms for minimizing medication errors. In the cross-sectional study for assessing the effect of double-check reporting during the Med administration of high-risk drugs, Koyama et al. (2020) reported an inconclusive conclusion implying that more research has to be done in order to determine the exact benefits of this practice. Lastly, Manias et al. (2020) conducted a systematic review to compare different interventions to reduce medication errors in acute medical, and surgical care setting; and pharmacist-led medication reconciliation, computerized physician order entry were found to be effective. Altogether, these works suggest that medication errors are rather common in healthcare contexts stressing the need to employ various-combined strategies to build a safer healthcare environment.
It is highlighted from the analysis of several different articles that medication errors are complex and essential issues for consideration in healthcare facilities. Such mistakes which may happen in different phases of medication present critical threats to the safety of the patients and provoke critical questions concerning the efficacy of the healthcare system. Basing on the annotated bibliography derived from this (NHS-FPX 4000 Assessment 2)study, it can be concluded that there is need for a multi-pronged strategy that includes well developed reporting system, cross-discipline teamwork, implementation of standard protocols, and massive training to reduce these risks. Further studies and the into the practice of frameworks that have been found to be effective in minimizing medical mistakes and improving the general quality of organizations managing healthcare.
Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1), 1–10. https://doi.org/10.1186/s12913-021-07187-5
Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025
Koyama, A. K., Maddox, C.-S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of Double Checking to Reduce Medication Administration errors: A Systematic Review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552
Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1), 1–29. https://doi.org/10.1177/2042098620968309
Portillo, I. A., Johnson, C. V., & Johnson, S. Y. (2021). Quality evaluation of consumer health information websites found on google using DISCERN, CRAAP, and HONcode. Medical Reference Services Quarterly, 40(4), 396–407. https://doi.org/10.1080/02763869.2021.1987799
Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024, February 12). Medical error reduction and prevention. National library of medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Tariq, R. A., & Scherbak, Y. (2024). Medication dispensing errors and prevention. National library of medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/