Medication Error Causes

Padula, & Steinberg. (2021). What current and missing data can teach us about medication errors. BMJ Quality & Safety; London, 30(2), 89–91. https://doi.org/10.1136/bmjqs-2019-010555

The purpose of this article is to discuss medication errors in an ever changing and evolving healthcare system. The article explains several ways in which medical errors happen, and not just in a hospital system. In hospital systems, we have the five right of medication administration, right patient, right drug, right dose, right route and right time, a healthcare standard that is used to reduce the amount of medication errors. There is also increased technology, barcode administration, electronic medical records and self-reporting standards that help us better understand how medical errors happen. A factor that is hard to control is the home setting, are medications prescribed correctly and if they aren’t, how is the problem caught? Home patients often don’t know a medication error has occurred making it difficult to research how the medication error occurred in the first place. The article goes on to explain how we can better communicate medication errors and how to help eliminate future errors. Better communication between physicians and pharmacists could help eliminate many of the errors that occur in the home or outpatient setting as well as better ways to report medication errors. This article was chosen as it digs into many of the ways medical errors occur, including areas outside of a hospital setting.

Savva, Papastavrou, Charalambous, Vryonides, & Merkouris. (2022). Exploring Nurses' Perceptions of Medication Error Risk Factors: Findings From a Sequential Qualitative Study. Global Qualitative Nursing Research, 9(23333936221094857). https://doi.org/10.1177/23333936221094857

The purpose of this article is to discuss the findings from a focus group compiled of nurses to determine their perception on the cause of medication administration errors. There were four themes identified through the focus group that helped narrow down where most medication errors are made. Depending on the setting they work in, hospital nurses spent approximately 27% of their time on medication related tasks. The four themes were professional practice environment, person-related factors, drug-related factors, and processes and procedures. From there, 33 sub-categories were discussed in length to determine what factors were most prevalent in causing medication errors. Factors such as staffing, technology failures and everyday distractions were agreed upon to be huge factors in what cause the errors. This was included as an important resource for medication errors as it is focused on the nurses’ perception of medication errors first hand.

Wondmieneh, Alemu, Tadele, & Asmamaw. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals. BMC Nursing; London, 19(1). https://doi.org/10.1186/s12912-020-0397-0

This study was done by interviewing 298 nurses in a hospital to determine what they believed were contributing factors to their medication errors. The top reasons reported for medication errors occurring were lack of adequate training, lack of proper resources for the medication administration,

inadequate work experience, distractions and interruptions, and night shift duty. This article gives information on why medication errors are important, how they affect patients and what the costs are to the hospitals where the error occurs. The result of the study was that continuing education is an important part of medication administration, and continuing education for all nurses may prove an effective was to reduce medication errors. This resource was provided as a way to learn about the reasons medication errors occur and ways in which those errors can be reduced.

Yussuf, Mustafa, & Al-Qahtani. (2021). Prevalence, types and severity of medication errors associated with the use of automated medication use systems in ambulatory and institutionalized care settings: A systematic protocol. PLOS ONE, 16(12). https://doi.org/10.1371/journal.pone.0260992

The purpose of this article is to discuss the link between technology and medication administration errors in the healthcare setting. Systems such as electronic medical records, computerized physician order entry systems, and bar code administration systems have all helped reduce medical errors by 37%. The use of automated systems in medication administration has reduced the amount of medication errors therefore, reducing patient injury and the financial burden of medication errors. However, as the article discusses, relying on technology often gives a false sense of security, relying on technology to catch our errors instead of catching the error ourselves. While technology can help reduce the number of errors in medication administration, it has its own set of flaws such as the ability to override and manual workarounds. The article sets out to determine the how often medication errors are made, the severity of the error and the type of error made with automated medication systems. This article was chosen as it highlights one of the many reasons medication errors can occur and is something that almost every healthcare setting has in place for medication administration today.