Medication Administration Errors and Safety Improvement


Patient safety always takes top priority in the healthcare industry, requiring considerable attention, effort, and resources to develop appropriate strategies to protect patients from unexpected, adverse events. In this regard, medical providers encounter numerous issues while delivering care, the primary of which is medication administration. This problem frequently causes prolonged hospital stays, readmissions, physical and psychological harm, and even death. Therefore, this paper aims at providing a root-cause analysis of a safety issue, namely, medication administration errors (MAEs), relevant strategies, a safety improvement plan, and identifying organizational resources.

Root-Cause Analysis

Despite wide-range healthcare improvements that provide quality treatment and safe care, MAEs in medical practice remains an ongoing, debilitating concern. Clinicians access an arsenal of over 10,000 recipe drugs, and over thirty percent of adults take more than five drugs in the United States. Globally, according to different findings, 18%-56% of hospitalized patients encounter this type of fault (Tsegaye et al., 2020). In the USA, MAE is a global challenge, and 19%-56% of hospitalized patients face medication administration errors. Intravenous MAEs had a higher mistake rate, accounting for fifty percent. Adverse drug events (ADEs) amount to about 700,000 visits to the emergency department and 100,000 hospitalizations every year (“Medication errors,” 2019). It is worth noting that MAE is one of the most prevalent avoidable events in the healthcare sector, comprising nearly 10 percent of all preventable harm (Tsegaye et al., 2020). In an outside hospital setting, patients also face this problem frequently; mistakes at home possess rates between 2-33 percent (“Medication administration errors,” 2019). Wrong dose, wrong medication, and missing doses are the most typically reported MAEs.

MAEs usually stem from clinician-specific, drug-specific, patient-specific risk factors. The clinician-specific aspect is mainly related to inadequate communication practice between physicians, nurses, and patients. In particular, Hammoudi et al. (2017) indicate that nurses and doctors conduct poor clarifying work with patients concerning their medication packaging that can have drugs with similar names and be easily confused. Besides, physicians often give unclear verbal instructions to nurses or neglect to provide them with necessary orders. Moreover, Wondmieneh et al. (2020) state, “Nurses who didn’t use guidelines for medication administration were two times more likely to make MAEs than those who had used guidelines for medication administration” (6). They also add that work experiences and training also play a significant role in MAEs occurrence. Doctors are frequently inclined to prescribe medication, especially opioids, antidepressants, and sedatives, an excessive amount or without a real need. For example, a recent study showed that, between 2004 and 2012, opioid prescriptions increased drastically after low-risk surgical and dental procedures. Finally, staff overload, shortage, and interruptions considerably impact safety provision in terms of this issue.

Patient-specific factors are primarily determined by the age of the patients and their age-associated illnesses. In particular, elderly patients tend to have a broader list of medications than youngsters, and they are also more subjected to side effects in case of overdose. Pediatric patients also incur higher risk because drugs should be dosed considering their weight and health condition. Other roots for MAEs comprise limited critical thinking and literacy, especially regarding medicine and health.

Concerning medication-linked factors, the Institute for Safe Medication Practices establishes a list of high-alert medications that can inflict potent harm to patients if applied inappropriately. These drugs possess hazardous adverse effects, especially for vulnerable patient categories. In this regard, the Beers criteria are utilized to evaluate medication safety for geriatric patients (“Medication errors,” 2019). In addition, look-alike and sound-alike medications, that is, those with similar titles and entirely different pharmaceutical properties, also relate to high-alert drugs.

Evidence-Based Strategies

Evidence-based strategies primarily pivot on prevention measures, patients’ and personnel education, conducive environment, corporate culture, and organizations’ policy. First, health care providers should follow standardized communication that minimizes possible errors with taking drugs and helps patients clarify different issues in their recipes. Second, healthcare professionals provide strategies that promote robust patient education since they mitigate the risk of errors at home and eliminate difficulties in medication regimens.

In medical settings, there is an acute need to optimize nursing workflow to reduce distractions and interruptions during medication administration. The decreased workload can allow for independent double checks, which also require involving two different nurses. In this respect, a systematic review by Koyama et al. (2020) identifies a considerable positive correlation between double-checking and MAEs’ reduction. Third, healthcare organizations should always ensure the appropriate education of their personnel and provide training in the case of need. In this regard, medication safety rounds or medication pass audits are critical educational tools for health systems and correct nursing practice. Finally, managers can implement high-tech solutions, including barcode scanning of medication or smart infusion pumps.

Safety Improvement Plan

The design and implementation of a safety improvement plan (SIP) help healthcare providers direct safety improvement efforts to achieve specific outcomes in focused areas. Regarding MAEs, a SIP will pursue five objectives: enhancing patients’ and nurses’ education, improving environmental conditions, cultural strategies, clinical interventions, and technological interventions. To attain the first goal, the management should utilize and promote a combination of education practices, such as close face-to-face discussions between various professionals and strict adherence to medication administration guidelines (Heng et al., 2020). The second goal assumes streamlining nurses’ workflow and alleviating workload. Cultural strategies imply highlighting a multidisciplinary responsibility for errors prevention, whereas clinical interventions mean minimizing opioid and sedative medications. Finally, technological interventions involve using barcode scanning of medication or smart infusion pumps. The realization of the plan will demand three or four months, and the results will rest on staff’s, patients’, and management’s commitment to the objectives, especially concerning education.

Organizational Resources

Portland VA Medical Center (PVAMC) is the central medical facility of the US Department of Veterans Affairs, the most powerful and technologically advanced health care system for veterans in the US. This organization employs around 400,000 workers and operates over 1,800 sites of care, including 171 medical centers, 300 vet centers, and 1,283 outpatient sites across all 50 states (“VA Benefits,” 2021). PVAMC is a consolidated facility with 303 beds, situated on Marquam Hill on 28 acres, looking to Portland city (“Portland VA,” n.d.). The center is connected with Oregon Health & Science University (OHSU) functionally by shared trainees, staff, and educational capabilities. PVAMC specializes in primary, intermediate, long-term, acute, rehabilitation, and surgical care and provides services such as mental health, cardiology, optometry, orthopedics, gastroenterology, gynecology, and others.

In summary, this paper has delivered a root-cause analysis of medication administration errors, relevant strategies, and a safety improvement plan and identifying organizational resources. According to the Patient Safety Network, ADEs amount to about 700,000 visits to the emergency department and 100,000 hospitalizations every year. MAEs can be caused by clinician-specific, drug-specific, and patient-specific risk factors. The clinician-specific aspect includes inadequate communication policy, low compliance with guidelines, medication overdose, and staff overload, shortage, interruptions. Age and associated illnesses and limited literacy are among patient-specific factors. The evidence-based interventions imply patients’ and personnel education, standardized communication, a conducive work environment, double-checking, medication safety rounds or medication pass audits, and high-tech strategies.


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