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Causes and Prevention of Medication Errors

With cardiac and cancer fatalities being the number one reason for
deaths, preventable medication errors was the number three leading cause
for hospital deaths (Binder, 2013). Patients turn to hospitals for times of
medical emergencies, relief from pain, and medical treatment. The irony
behind the reasons of why they turn to hospitals in the first place is that
patients sometimes do not feel better than when they first got admitted.
Throughout this paper, the cause and prevention of medication errors will be
examined using articles based on quantitative and qualitative studies.
Causes of Medication Errors
Medication error and adverse drug events are a frequent source of
error in healthcare and are associated with an increased burden of illness for
patients and higher costs of hospital treatment (as cited in Redley, 2012).
Adverse drug events are defined as injuries resulting from the use of a drug
(as cited in Agyemang, 2010). These medication errors could occur during
prescribing, dispensing, and administration of the drugs. As registered
nurses, careful preparation and administration of drugs should be practiced
to minimize harm and fatality in the workforce. Furthermore, in order to
minimize medication errors, the Department of Health (2004) has identified
the five rights of drug administration: right medication, right dose, right
time, right route, and right patient (as cited in Agyemang, 2010). According
to Redley, 2012, even though computerized medication management
systems (MMS) has been introduced to improve the safety and efficiency of

medication management, the article indicates that MMS may provide

benefits in some aspects of medication safety but it may also introduce other
issues for consideration and further investigation. Other factors related to
medication errors are: stress and fatigue, knowledge of medication,
distractions and interruptions, use of IV infusion devices, illegible
prescriptions, heavy workload, multi-tasking and medication packing/labeling
(LASA drugs) (Agyemang, 2010).
Prevention of Medication Errors (Supporting Evidence)
The Joint Commission (TJC) addresses drug errors with several of its
National Patient Safety Goals (NPSGs). JCAHO mandates that all JCAHOaccredited hospitals be required to meet the NPSGs, which are updated each
year by a group of experts in patient safety, medicine, nursing, and
pharmacy. The three must-haves of NPSGs are: 1) stock drugs in
standardized concentrations, 2) compile a list of at least 10 look-alike or
sound-alike drug pairs (also known as LASA), and 3) label all medications,
medication containers (such as syringes), and other solutions on and off the
sterile field (Metules, 2007). To further ensure the prevention of medication
error, it is also wise to determine the use of each drug for each patient,
recognize both, the generic and trade names of the drug, and store drugs
with similar names and looks in different places. As a registered nurse, it is
never safe to assume. When there is doubt, always double or triple check
with two other licensed staff.
Literature Review


article, Medication errors: types, causes and impact on nursing

practice, was based on a qualitative research method. The study was done
in two London teaching hospitals involving 1014 admissions. Because this
article did its research on two hospitals, the results provided a depth and
richness of data. Due to the restricted amount of participants, data was
analyzed in a more detailed manner within the two hospitals. Replicability
and validity is also expressed in past studies, there is evidence that
administration errors are common forms of medication errors; Leape et al
(1995) found that 39% of medication errors occurred during the doctor
prescribing stage and 38% during the nurse administration stage, with the
rest occurring equally between the transcribing and dispensing stages of the
medication process (as cited in Agyemang, 2010, p. 381). This article did
not have any statistics or numbers, but the data between two groups were
compared and contrasted.
On the other hand, the article, Reported medication errors after
introducing an electronic medication management system, was based on an
non-experimental quantitative research method. The entire article was
based on a descriptive analysis of 359 medication error reports where two
hospitals were examined for cause and effect. The independent variable
(introduction of electronic medication management system) was compared
with the control group (pen and paper system) to measure medication errors.
The findings were organized using a column chart and a table with numerical
values showing statistical analysis expressed quantitatively. Conclusively,

the data showed that there are different types of medication errors reported
when using the conventional pen and paper method compared to the
introduction of electronic medication management system.
The quantitative research concluded that pen and paper method
produced more errors on omission, while the electronic medication
management system produced more errors on wrong documentation. Both
personal and organizational factors that contribute to medication errors.
Interesting enough, both studies suggests that physicians need to transcribe
legibly so the errors do not go down a trickle effect to create more future
Rationale for selecting the solution (best nursing practice)
Quantitative and qualitative research both yielded similar results, in
that medication errors occur in transcribing, dispensing, and administration
stages. Regardless of a MMS being implemented or a pen and paper system
is being used, it is imperative to keep in mind the entire process and
procedure of medical administration. Based on the evidence provided, the
best nursing practice is to triple check the Medical Administration Record
during prepping and dispensing, and prior to administering, using the five
rights. Both studies emphasized that nurses need more training on hospital
policies and procedures, practice the five rights, and that nurses are the last
person to triple check during administration to prevent medication errors.

Whether the pen and paper system or electronic medication

management system is in place, it is important to never rely solely on
technology. It is wise to not assume what the physician prescribed. Humans
inevitably make mistakes that can cause fatality.
Registered nurse must make sure the right dosage, drug, route, patient, and
time is correct before and during administration. Based on the evidence, in
spite of the implementation of electronic medication management systems,
medication errors still occur. Personal and organizational factors also affect
medication errors. However, diligently following the five rights and keeping
in mind that a single mistake can potentially cause patient fatality could
prevent the error. New technology along with other precautions, and being
extremely detail oriented could be the best precaution to minimize the rate
of deaths and harm from medication errors.

Agyemang, R. E. O., While, A. (2010). Medication errors: types, causes, and
impact on nursing practice. British Journal of Nursing , 19 (6), 380-384.
Binder, L. (2013, September 23). Stunning News on Preventable Deaths in
Hospitals. Retrieved from
Metules, T. J., Bauer, J. (2007). JCAHO's Patient Safety Goals: Preventing med
errors. RN , 70 (1), 39-44.
Redley, B., Botti, M., (2012). Reported medication errors after introducing
and electronic medication management system. Journal of Clinical
Nursing , 22, 579-589.