Running Head: PATIENT SAFETY

Patient Safety, Quality and Informatics

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Patient safety issue: medication administration error

PATIENT SAFETY

One of the most important patient-safety issue in my organization is medication

administration errors. Medication administration errors have been detected in the hospital and if
unaddressed, could lead the organization to become subject of litigation especially if the
medication error proved fatal to the patient. These errors are nothing new to the profession,
given the complex nature of the medication administration process. It requires those that
administer drugs mostly nurses and pharmacists to prescribe, transcribe, dispense, and
administer drugs as well as to monitor how the patient responds to the administered drug
(Aronson, 2009).
Throughout this complex process, errors are made but timely detection and interception
can reduce errors. However, in the end, errors still persist. There was an instance wherein a nurse
erroneously gave penicillin to a boy without first determining whether he was allergic to it.
However, the problem of medication administration errors persist in my organization due to
various reasons and all at the expense not only of the hospitals reputation but its capability to
deliver competent medical service as well as staff morale. In my own determination and informal
interviews with nurses, most of the errors are knowledge-based errors, which stem from lack of
knowledge due to incomplete information regarding the drug being administration and the details
and background of the person about to receive the drug. Sometimes, details about the patient
come late and are not considered in the prescription process. Moreover, one of the biggest
problems in the organization which facilitate medication administration errors is the poor
communication among physicians, pharmacists and nurses. Aside from poor communication,
those whom I interviewed stated that they commit mistakes, lapses, and slips in medication
administration due to work-related fatigue, stress, and the physical exhaustion associated with
their respective jobs.

PATIENT SAFETY

The organization and patient safety culture

Reducing or eliminating medication administration errors requires the formation of
patient safety culture in the organization. The Institute of Medicine (IOM) reported that medical
errors lead to 44,000 to 98,000 deaths annually. In fact, medical errors are ranked as the eighth
leading cause of death, followed by AIDS, breast cancer, and vehicular accidents (as cited in
Ajami & Bagheri-Tadi, 2013).
Patient safety begins with creating a culture of safety within the organization (Nieva &
Sorra 2003). Moreover, Reason (1997) stated that there are four major components of safety
culture in organizations, including a just culture, a reporting culture, a learning culture and a
flexible culture (p. 32). In the context of a hospital, patient safety culture means developing an
environment with proactive staff and having organizational commitment to patient safety.
One important element of the culture of safety is teamwork, or the quality of
communication and collaboration among the staff (Halligan & Zecevic, 2011). This necessarily
means how physicians, nurses and pharmacists collaborate in order to promote patient safety.
Among the care providers in the hospital, there is a fairly good amount of teamwork among
nurses and attendants while there are incidents wherein issues between nurses and attending
physicians. I have personally observed nurses breaking down in tears because of altercations
with attending physicians who might believe that the essence of teamwork is to do what you are
being told. Some nurses have also explained that the quality of teamwork in the organization is
compromised because they perceive their inputs as being ignored altogether. However, this might
be attributed to the multidisciplinary character of the organization. While there are sources of
conflict, the general level of teamwork observed among nurses, physicians, and pharmacists is
fair.

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Quality of communication is an important feature in promoting patient safety culture

(Clancy, 2011). Some of the problems that the organization has regarding communication is the
lack of time as well as external interruptions needed in order to have face-to-face discussions on
medical administration issues. For instance, verbal orders coming from physicians are sometimes
not verified by physicians themselves while handwritten orders from them are illegible,
sometimes leading to medication errors. There are also instances where communication breaks
down due to role ambiguity, wherein some personnel are perceived to be encroaching on
functions reserved by another discipline.
Another important concept in the formation of patient safety culture is the organizational
commitment to safety (Aronson, 2009). There have been no fatal medication errors which
occurred in the hospital as of yet but there are several instances of wrong administration of
medication. The care provided in the hospital is fairly safe and while there are medication errors,
these are not fatal and occur only in a low rate. However, the incidence of medication errors have
increased in frequency for the past year. The possibility that the recurrence of medication errors
if not addressed properly will escalate in growing seriousness is imminent. Factors leading to
medication errors are usually due to individual factors such as lack of knowledge and
inadvertence due to failure to adhere to protocols. Other factors which make care providers in the
hospital susceptible in committing medication errors are exhaustion, distraction, poor
communication and high workload. The organization is not fully compliant with evidencebased guidelines and protocols that nurses and physicians must follow. There is satisfactory
adherence on the guidelines but these are not consistently complied with due to the high
workload; as a result, doing shortcuts in order to accomplish tasks becomes the order of the day.

PATIENT SAFETY

In terms of having a reporting culture, the error and incident management system in the
hospital is still a work in progress. There is a critical incident form which all care providers are
required to provide details to and to report major errors. While the staff is aware of these
reporting guidelines, most prefer to make informal reports to the head nurse instead of filing
formal reports. Some are hesitant to report errors committed by their more senior co-workers.
In terms of promoting patient safety culture through job satisfaction, the reality of
exhaustion and stress in the care industry is apparent. Staff morale is often pulled down due to
high workload and emotional problems associated directly with the provision of care. In my
organization, many nurses have quit their jobs due to the pressure and emotional exhaustion.
There is also perceived monotony of job due to the routine nature of the activities included. Most
nurses I know who have provided end-of-life care share their stories of depression.
Legal and ethical consequences of medication errors
Medication errors are not the cause of any health problems. They are however the cause
of injury or death of a small percentage of the population. Not only is the impact of medication
errors felt by the patient affected, it also has a profound and lasting impact on the health
practitioner who were involved in the error. In cases of fatal medication errors, health
practitioners need to come to terms with the death of another person due to their acts and have to
grapple with civil claim for damages which arises out of the death. For the institution,
involvement of a physical over a fatal medication error can subject the institution to discipline
and review of privileges. There is also the potential for the involvement of a regulatory college to
impose penalties on an individual and possibly bar him or her for life from practice in the health
profession. Hence, tremendous implications arise from medication administration errors.

PATIENT SAFETY

Studies have shown that the consequences of medical errors include health, care, time,
and financial consequences. Medical errors cause pain, illness and emotional or psychological
harm to the patients and their families. Errors also lead to delayed diagnosis and hence delayed
treatment of illness including disruptions to much-needed care among patients (Bonney, 2014).
As an ethical obligation, patients need to be informed of medical errors. Patients have the right to
disclosure in order to be capacitated in making informed decisions and judgments. A failure to
disclose information on medical errors will affect care decisions, compromise the patient-doctor
trust and may be the cause of litigation. Hence, it is the legal and ethical obligation of healthcare
providers and professionals to disclose medical errors. Some hospitals have a disclosure plan
which includes a timeline and communication strategy for disclosure to the general public as
well as a system wherein affected patients can follow up their cases individually to review errors
and recommend changes (Reader et al., 2007). The reality is that disclosure of medical errors to
patients is excruciating to care providers. Aside from the time-consuming and resource-intensive
nature of disclosure involving multiple patients, it might create in-fighting among the healthcare
practitioners involved. However the case may be, institutional policies regarding disclosure of
errors to patients need to be put in place.
Evidence-based interventions
Prevention, reduction and elimination of the incidence of medical errors require
institutions to identify the causes, devise solutions, and measure/monitor improvement. While
there are several legal, financial, and ethical consequences arising from medication errors, these
errors are preventable. Evidence-based practices and findings may be used in order to
accomplish error-free medication administration in care institutions.

PATIENT SAFETY

The literature is unanimous in saying that preventing medication administration requires

leadership, commitment, and resources. Literature also states that organizations who have
formed a positive safety culture have a proactive response to errors or what is called double
loop learning (Nolan, 2000). This means that organizations are proactive when they detect
errors and learn from them by coming up systemic reforms in order to prevent future errors from
occurring. The traditional mode of response among hospitals with respect to medication
administration is reacting because only immediate actions were taken without addressing the root
causes of medication administration errors. Developing a patient safety culture in healthcare
institutions require the establishment of systemic error management techniques in order to
mitigate damage resulting from medical errors. There are evidence-based error management
techniques proposed by researchers. Nolans (2000) proposal is for institutions to implement
strategies dealing with the design of:
(a) systems which will prevent medical errors;
(b) systems which will make visible medical errors committed; and
(c) systems which mitigate unforeseen medical errors;
Nolan also proposed that these strategies need to be implemented with tactics that involve wise
automation and information processing so that the whole process reduces complexity.
The role of technology
In this context of implement preventative systems to reduce errors, technology has a
significant role. The use of healthcare information systems such as Electronic Health Record
(EHR), Electronic Medical Record (EMR), and CDSS have been proven to effective in
preventing medical errors (Ajami & Bagheri-Tadi, 2013). The advantage in using these systems

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are they prevent medical errors because they enforce adherence to evidence-based practices
thereby enhancing the clinical decision-making process.
Electronic Health Records (EHRs) are digitized healthcare information of a person
containing relevant details throughout that persons lifetime (Ajami & Bagheri-Tadi, 2013).
EHRs may store data on laboratory tests, observations, treatments, drugs administered, legal
permissions, identifying information and other information. With the advent of global
integration, proving adequate and accurate health information is a big boost to achieving
competence in the healthcare industry. The paper record system makes the entire process tedious
and does not respond to care needs in a manner close to electronic means. Studies have reported
that using EHR systems would amount to savings in billions of dollars for institutions per year in
addition to improving the quality of care. However, institutions are shying away from
implementing these systems due to the low return on investment when compared to the massive
costs in adopting the EHRs systems.
Possible organizational barriers towards change
There are several barriers in the implementation of EHRs system as a response to
medication administration errors. Adoption of electronic health records are costly and laden with
interoperability and other technical challenges (Ajami & Bagheri-Tadi, 2013). Of all situational
barriers, the financing impediment is the greatest barrier. Some have asserted that the
implementation of EHRs systems only guarantee only 11% of the ROI, making it insignificant
from the cost-benefit viewpoint. System and interoperability issues are also a concern because
most of the health care data available are in silos (Kaye et al., 2010). Liability barriers are
those concerning privacy and confidentiality. Another barrier is the lack of competent workforce
which will implement the technology reform. A last and significant barrier is cognitive barriers

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due to resistance to the reform itself from the health care practitioners who are expected to
frontline its implementation (Kaye et al., 2010).
Strategies to overcome barriers
In the context of my organization, the two most significant barriers to implementation of
EHRs systems to reduce or eliminate medication errors include: financing and cognitive barriers
(Ajami & Bagheri-Tadi, 2013). The decision itself to invest in IT for improvement of patient
safety and care requires a commitment and visionary leadership. Making and implementing such
a decision to use technology for care reform requires an integrated responsibility among the
hospitals leaders in collaboration with its clinicians. In order to make the vision work, there
needs to be a discussion and presentative of empirical and quantitative data to assess the pros and
cons of installing IT systems. Debates on ROI are to be expected but through an honest and
transparent evaluation of strategies, the collaborative atmosphere will produce strategies as well
on how to contain the costs associated with the implementation of technologies.
To this end, a multidisciplinary working group consisting of the hospital managers,
clinicians, nurses, IT people and other practitioners can be created in order to develop a shared
vision of the IT system. There must also be financial incentives provided to clinicians who will
lead the implementation of the system. Additional training and ongoing support for clinicians
must be assured by leadership.
In order to address the cognitive barriers towards implementation of the IT system,
additional education on the hazards of medical errors must be made. Many in the care profession
are resistant on the process of managing medical errors. Medical education can help enhance
their awareness on the severity of this patient safety issue. Most importantly, the institution needs

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to be developed into an enabling environment where practitioners can disclose and discuss
medical errors without fear. A fair disclosure policy can be crafted as a strategy.

References
Ajami S, & Bagheri-Tadi T. (2013). Barriers for Adopting Electronic Health Records (EHRs) by
Physicians. Acta Inform Med. 21(2):129134. doi:10.5455/aim.2013.21.129-134

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Aronson, J.K. (2009). Medication errors: what they are, how they happen, and how to avoid
them. QJM: An International Journal of Medicine, 102 (8), 5130521. DOI:
http://dx.doi.org/10.1093/qjmed/hcp052
Bonney, W. (2014). Medical errors: moral and ethical considerations. Journal of Hospital
Administration 3(2), 80-88. DOI: 10.5430/jha.v3n2p80
Clancy, C. (2011). New research highlights the role of patient safety culture and safer care. J
Nurs Care Qual. 26,193-196.
Halligan M. & Zecevic A. (2011) Safety culture in healthcare: a review of concepts, dimensions,
measures and progress. BMJ Quality & Safety 20 (4), 338.
Kaye, R., Kikia, E., Shalev, V., Idar, D. & Chinitz, D. (2010). Barriers and success factors in
health information technology: a practitioner's perspective. Journal of Management &
Marketing in Healthcare 3(2), 163-175. DOI: 10.1179/175330310X12736577732764
Nieva V. & Sorra J. (2003) Safety culture assessment: a tool for improving patient safety in
healthcare organizations. Quality & Safety in Health Care 12 (Suppl 2), ii17ii23.
Nolan, T.W. (2000). System changes to improve patient safety. BMJ. 320,7713.
Reader T.W., Flin R. & Cuthbertson B.H. (2007) Communication skills and error in the intensive
care unit. Current Opinion in Critical Care 13 (6), 732.
Reason, J., (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing Ltd,
Aldershot, Hants

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