Sample Research Paper on Analyzing Health Care Problem of Medication Errors

The chosen topic for this assessment was medication errors, a significant challenge for
the contemporary healthcare setting. Walker (2016) defines a medication error as “… any
preventable event that may cause or lead to inappropriate medication use or patient harm while
the medication is in the control of the health care professional, patient, or consumer” (p.125).
This definition highlights the crucial role played by different stakeholders in ensuring high-
quality care and effective treatment of patients. Essentially, the entire healthcare organization,
clinical personnel, nurses, and patients have a role to play in minimizing medical errors.
Effective treatment depends on the execution of medical guidelines and adherence to prescribed
medication in terms of dosage and timelines. As noted, medical errors are preventable.
Nonetheless, these errors continue to cause significant mortality and morbidity challenges
worldwide. For instance, the United States loses over 90,000 citizens annually to medical errors
(Muroi, Shen & Angosta, 2017). Additionally, medical errors increase treatment costs, hospital
stays, reduce patient safety, and contribute to reduced quality of care for patients in hospitals.
Given the role played by all stakeholders in the healthcare system in instances of medical errors,
all of them have to come together in seeking solutions and minimizing the risks of the same.
Addressing medical errors in healthcare calls for organizational reorganization and reform and
training and education for nursing personnel.

Major Elements of Medication Errors

Medication errors have been found to have various contributing and risk factors. These
include the hospital unit, prescribed medication, and human factors. The human factors deal with
the characteristics of the patient and the resident nurse (RN). For instance, a nurse might
prescribe medication to a patient who is taking other health supplements or herbs which are

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easily available over-the-counter in contemporary society. As a result, a medical error occurs
when such a patient takes the prescribed medication and it reacts with the over-the-counter
medication they have been taking (Walker, 2016). Further, the characteristics of the nurse,
including the skills, knowledge, education, cognitive, and physical status can all contribute to
medical errors (Di Simone et al., 2018; Gracia, Serraon & Garrido, 2019). The mistakes of RNs
have been particularly fingered for contributing to medical errors compared to other medical
professionals (Walker, 2016). Mostly, nurses are responsible for medication administration to
patients and are therefore more likely to face such challenges.
The hospital unit or department in which a patient is admitted also determines their risk
of medical errors. According to Muroi, Shen, and Angosta (2017), the intensive care unit (ICU)
and the surgical department are more prone to medical errors within a hospital. Further,
prescribed medications such as antimicrobials and cardiovascular drugs, typically administered
in the ICU and surgical units, and are also highly responsible for medical errors (Muroi, Shen &
Angosta, 2017). This highlights the relationship between the organizational set-up of the
organization and individual human factors in contributing to medical error events in hospitals.
Essentially, a poorly staffed ICU, for example, would see the nurses fatigued and therefore more
likely to make prescription errors as they handle a high number of patients.

Analysis of Medical Errors

Medical errors are an important clinical issue for me given the problems it poses for the
well-being of the healthcare organization and the well-being of patients. Mainly, I understand the
profession requires diligence, adequate knowledge, and education to ensure positive outcomes
for all patients. Importantly, I believe it is vital for appropriate reporting measures to be in place
to handle instances of medical errors. Reporting mechanisms ensure that medical errors are

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identified, analyzed, and remedial measures are taken to prevent future occurrences. This
requires a close relationship between all healthcare stakeholders from hospital staff, board
members, and patients to create a conducive environment for treatment.
The context for Medication Errors

Prescription and nonprescription drugs can often cause negative effects on patients be it
at the hospital or the home level. This implies that medication errors can take place in different
locations and not solely in hospitals. As discussed, medication errors involve an interplay
between human and hospital organization factors (Walker, 2016). The human factors often
occur due to erroneous prescription, administration, monitoring, and dispensing challenges. For
instance, an error may occur due to wrong dosages or prescription of wrong medication. Further,
confusing drug names, packaging confusion, and ineligible handwriting by physicians may
contribute to the problem. Organizational factors, including the absence of error reporting
mechanisms, limited error-detection mechanisms, and lack of support from top management, and
understaffing also contribute to the present challenge.
Affected Populations

Further, Patients in ICU are more prone to medical errors and such patients often
succumb given the nature of their illnesses. These units are often labor-intensive for the nurses,
features frequent staff changes, and may be characterized by communication challenges (Gracia,
Serrano & Garrido, 2019). Essentially, medical errors appear to be a consequence of
organizational shortcomings which are exacerbated by human errors. Primarily, nurses are the
most affected group by medication errors in clinical settings (Walker, 2016). Mostly, nurses
work at the bedside of patients as they provide the needed primary care. This often requires them
to have the requisite skills and knowledge to provide such care. In cases where such knowledge

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lacks, medical errors are more frequent and thereby contribute to adverse health outcomes for
affected patients.

Potential Solutions

As discussed, medication errors are preventable when a healthcare practitioner or
organization takes the necessary measures. The potential solutions include patient medication
safety training, medical staff training, and education, and implementation of a bar code
medication administration (BCMA) system.
Patient medication safety training provides crucial education and information to patients
on the appropriate administration of medication. This includes issues such as when to take
medication, dosage amounts, how to report adverse effects, what to do when they miss doses,
and when to seek additional treatment. The medical staff, primarily the nurses, should also
receive the necessary training and education to handle different medications and effectively
administer the same to patients without errors (Bjorksten et al., 2016). Indeed, Gracia, Serrano,
and Garrido (2019) in their study highlight that only about 15 percent of nursing practitioners
had pharmacological knowledge. This is problematic as they might give wrong prescriptions or
mixtures which may affect patients. Such training is vital to ensure they remain up-to-date about
new medications and treatment procedures.
The implementation of a BCMA system is crucial to reducing instances of medication
errors. According to Shah et al. (2016), the BCMA ensures that a nursing professional can
electronically verify the appropriate route of administration, time, drug, dose, and right patient
for a given prescription. Essentially, the nurse uses the BCMA to scan a patient's details at their
bedside and it immediately retrieves medication information from the hospital database on a
specific patient (Shah et al., 2016). This way, digital technologies such as the BCMA improve

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the efficiency and accuracy of drug administration ensuring minimal errors. The BCMA is
advantageous as it improves drug administration errors by close to 50 percent (Shah et al., 2016).
Further, BCMA is cost-effective as it improves billing and documentation in the hospital thereby
improving work processes. However, the BCMA technology can face challenges during power
outages. Also, erroneous algorithms or viruses might adversely affect the entire hospital in cases
of wrong identification by the BCMA.

Ethical Implications of Implementing BCMA

BCMA implementation requires a hospital to install significant internet and
communication technologies in their facility. The hospital also needs to purchase bar code
readers and unique identifiers for patients in the wards. Whereas the initial costs might be
expensive, the benefits soon outweigh any such costs. For instance, medical errors go against the
ethical principles of beneficence and nonmaleficence. These require nurses and the entire
hospital to cater safeguard the well-being of patients. However, medication errors increase
hospital stays, healthcare costs, and may result in costly litigation against a healthcare
organization (Shah et al., 2016). The implementation of BCMA ensures that the hospital can
maintain beneficence and nonmaleficence by promptly providing appropriate medication to
patients when needed with minimal errors witnessed. This way, patients can recover faster and
the hospital can cater to more patients within a community.
However, the BCMA might reduce accountability principles in healthcare ethics.
Accountability calls for practitioners to take responsibility for their actions and also report any
errors or adverse health effects to patients. Such accountability is crucial in medical errors given
that only about 5 percent of such cases are ever reported (Bjorksten et al., 2016). The BCMA
however, might reduce accountability in instances where the gadget fails to notify of erroneous

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reads. This may see a nurse continually administer medication to wrong patients before such an
error is detected.
Medication errors continue to cause healthcare challenges for many practitioners and
hospitals globally. These errors take place during the prescription, dispensing, and administration
of medicine to patients. They cause significant mortality rates globally with debilitating
consequences for affected patients. This is despite medication errors being preventable with the
use of appropriate techniques. This study recommends training and education of nursing
personnel on medication administration. Further, such education must also be provided to
patients to ensure they have knowledge of likely medication errors and how to avoid them. As
discussed, addressing the challenged calls for concerted efforts from patients, medical staff, and
hospital management to ensure increased adherence to the ethical principles of nonmaleficence,
beneficence, and accountability.

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References

Björkstén, K. S., Bergqvist, M., Andersén-Karlsson, E., Benson, L., & Ulfvarson, J. (2016).
Medication errors as malpractice-a qualitative content analysis of 585 medication errors
by nurses in Sweden. BMC health services research, Vol. 16(1), p.431.
https://doi.org/10.1186/s12913-016-1695-9
Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018).
Medication Errors in the Emergency Department: Knowledge, Attitude, Behavior, and
Training Needs of Nurses. Indian Journal of Critical Care Medicine, Vol. 22(5),
pp.346–352. https://doi.org/10.4103/ijccm.IJCCM_63_18
Gracia, E. J., Serrano, B. R. & Garrido, F. J. (2019) Medication errors and drug knowledge gaps
among critical-care nurses: a mixed multi-method study. BMC Health Services Research,
Vol. 19(640), s12913. https://doi.org/10.1186/s12913-019-4481-7
Muroi, M., Shen, J. J., & Angosta, A. (2017). Association of medication errors with drug
classifications, clinical units, and consequence of errors: Are they related? Applied
Nursing Research, Vol. 33(2016), pp. 180-185.
https://doi.org/10.1016/j.apnr.2016.12.002.
Shah, K., Lo, C., Babich, M., Tsao, N. W., & Bansback, N. J. (2016). Bar Code Medication
Administration Technology: A Systematic Review of Impact on Patient Safety When
Used with Computerized Prescriber Order Entry and Automated Dispensing Devices. The
Canadian journal of hospital pharmacy, Vol. 69(5), pp.394–402.
https://doi.org/10.4212/cjhp.v69i5.1594
Walker, E. E. (2016). Medication Errors. Imperial Journal of Interdisciplinary Research, Vol.
2(5), pp.125-131.

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