Issue of Medication Errors


Healthcare systems across the world are struggling to achieve the ultimate patient safety. One of the main factors in patient safety is medication errors as discussed in the previous assignment. Medication errors imply inappropriate use of medications by a patient under the care of a professional. The errors emanate from the mistakes made by medical personnel and the ultimate result is that the patients are harmed. The focus of this essay will be to offer a comprehensive description of this health issue and propose potential solutions. To achieve this objective, the essay uses the Socratic problem-solving approach, which identified problem elements, analyzes the problem, finds a solution, and implements the solution.

Elements of the Problem/Issue

Medical errors comprise the adverse and unintentional mistakes by medical practitioners with the use of medication that often leads to patient harm. Critical elements of medical errors include professional practice, health care products, systems, and procedures. According to Ambwani et al. (2019), the errors may involve communication, product labeling, prescribing, use, monitoring, and education. The decisions made by the staff affect the well-being of the patients. For example, a wrong prescription means that a patient gets drugs that are not intended for the illness, which could cause a deterioration of the health condition. Extreme cases of medical errors can have fatal outcomes where the death of patients is a possibility.

A further understanding of the elements of the problem can be achieved by classifying the errors into major typologies. Ambwani et al. (2019) present four categories: knowledge-based errors, action-based, rule-based, and memory-based errors. Knowledge-based medical errors are committed out of a lack of knowledge. The example offered is the case where a drug is prescribed without establishing that a patient could be allergic. Rule-based errors can be the result of bad rules or good rules being misapplied.

Carelessness and ignorance of the medical practitioners are the main cause of this class of errors. Memory-based errors can also be described as lapses, for example, having prior knowledge that a client is allergic to a certain drug but prescribed it having forgotten this information. Lastly, action-based errors are also referred to as slips and comprise unintended actions. For example, retrieving a medication instead of another, which was intended in the first place. Therefore, the core elements of medical errors comprise the practitioners making mistakes regarding knowledge, rules, actions, and memory. Most importantly, these practitioners are the main cause of the problem.



The context of the medical errors in the healthcare facilities and the medical personnel employed, including doctors, surgeons, and nurses. The errors are committed by the staff directly handling at least one aspect of a patient’s admission. Hospitals admit patients, undertake diagnoses, and prescribe drugs and other medication procedures. These processes can be handled by more than one group of hospital staff where each can make errors. For example, the personnel packaging drugs could mislabel them which could lead to a nurse or physician administering the wrong medication. Such a context is illustrated by Al Mutair et al. (2021), who find that the US recorded over 180,000 deaths of hospitalized patients from medical errors in the year 2008. Therefore, hospitals and other healthcare facilities present the general context of medication errors.


The importance of this problem is the fact that it affects the well-being and safety of patients. As explained earlier, the 180,000 deaths in 2008 illustrate the seriousness of medication errors (Al Mutair et al., 2021). Even though these numbers are outdated, it can still be argued that countries across the world continue to record preventable deaths and other health outcomes as a result of this problem. The prevalence of medication errors is manifested in many research studies, which further illustrates its importance,


The main groups of people affected by the problem include the patients and their relatives. According to Jaam et al. (2021), medication errors increase the risk of mortality and morbidity. Therefore, the patients can either die or suffer other critical health problems as a result of the errors. The amount of suffering to patients can also be extended to families and relatives who could grieve the loss of loved ones or simply witness the continued suffering of their relative from the mistakes of doctors. The practitioners are also affected because their mistakes and the underlying outcomes could affect them psychologically, especially guilt from being responsible for the negative health outcomes of their patients.

Considering Options

Multiple options have been proposed to help resolve the problem of medication errors. Jaam et al. (2021) recommend pharmacist-led education interventions based on the observation that most of the errors are associated with the prescription of drugs. The education focuses on helping the relevant personnel avoid obvious mistakes in their prescription practices. Lean six sigma has been proposed by Trakulsunti and Antony (2018), who find that the process improvements from implementing this model could prove critical in reducing medication errors. Lastly, an error reporting program is suggested by Al Mutair et al. (2021) where practitioners are required to immediately report any errors to allow for corrective action.

The argument is that errors that go unnoticed could be devastating while the risks could be mitigated through effective reporting. These options can be broadly described as error reduction, which means that they do not offer a possibility that all mistakes can be eliminated. However, it is important to acknowledge that human errors are subject to specific individuals and their competencies.


The solution selected from the available options is reporting, which is accompanied by such underlying practices as monitoring and double-checking medical checklists. According to Al Mutair et al. (2021), programs for monitoring errors that target triggers and influencing factors can be implemented to work with the reporting programs. Many practices in a hospital setting are undertaken with the use of well-established protocols and procedures that could follow given checklists. Double-checking these protocols and procedures against the actions of a medical practitioner could prove to be the most effective monitoring exercise to prevent medication errors.

Many hospitals may lack a formal reporting program, which could be interpreted as ignorance of its importance and the dangers posed by medication errors. While the other options are also critical, recording and reporting errors offer healthcare facilities the best chance to reverse the negative health outcomes because each error reported can be corrected where possible.

Ethical Implications

The ethical principles can be applied to the solution proposed. For example, the principle of justice requires the practitioners to ensure fair, appropriate, and equitable treatment of all patients. Reporting errors and allowing them to be corrected can be a means of pursuing justice for all victims of medical errors. Additionally, the principle of beneficence requires nurses to act for patients’ benefit, which included avoiding harming them. error reporting can be described as a mechanism to reverse or correct harm caused by medical errors.

From another perspective, it can be argued that error reporting is part of the ethical leadership in healthcare as described by Barkhordari-Sharifabad and Mirjalili (2020). The study by Barkhordari-Sharifabad and Mirjalili (2020) revealed that where ethical leadership was implemented in the nursing context, medical errors were significantly reduced. Therefore, reporting programs can be implemented as part of ethical leadership to reduce the detriments of medication errors.


Implementing the proposed solution requires establishing a communication framework that established the necessary reporting hierarchy. Where facilities have managers and supervisors overseeing the activities of the practitioners, the reporting system could comprise filling forms that are approved by superiors. In the forms, digital or manual, all actions are checked and confirmed, and potential areas where mistakes are possible are highlighted. The actions to be taken by the superiors depend on the nature and urgency of the error. Additionally, an emergency button on the facility’s medical or health records could be triggered in case of a serious error where a patient can be retrieved and properly treated.


Medical errors are detrimental to the safety and well-being of patients. Medical practitioners are the cause of this problem because errors are the result of their mistakes. A typology of the errors has been described to include rules, actions, knowledge, and memory. The patients are the main group of people affected by errors. Potential solutions have been highlighted, including reporting programs, which have been selected as the solution of choice.


Al Mutair, A., Alhumaid, S., Shamsan, A., Zaidi, A., Al Mohaini, M., Al Mutairi, A., Rabaan, A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 1-12. Web.

Ambwani, S., Misra, A., & Kumar, R. (2019). Medication errors: Is it the hidden part of the submerged iceberg in our health-care system? International Journal of Applied Basic Medical Research, 9(3), 135-142. Web.

Barkhordari-Sharifabad, M., & Mirjalili, N. (2020). Ethical leadership, nursing error and error reporting from the nurses’ perspective. Nursing Ethics, 27(2), 609-620. Web.

Jaam, M., Naseralallah, L., Hussain, T., & Pawluk, S. (2021). Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis. PLoS One, 16(6), 1-18. Web.

Trakulsunti, Y., & Antony, J. (2018). Can Lean Six Sigma be used to reduce medication errors in the health-care sector? Leadership in Health Services, 31(4), 426-433. Web.

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