Individual patients and groups visit health care facilities looking forward to comprehensive care and continuous support from health professionals. A holistic assessment of health issues, appropriate treatment, and healthy patient-provider relationships characterize such care. Despite multiple efforts to achieve this goal, numerous issues that hamper patient safety and care quality occur at different care points. Accordingly, health care professionals and leaders should explore these issues and their implications and implement sustainable, evidence-based solutions. Evidence-based solutions are informed by current research to ensure they are valid (Alrabadi et al., 2021). The purpose of this paper is to analyze a current issue in health care, including a proposed solution and possible ethical implications.
Scholarly Information Explaining the Health Care Issue
Medication errors are a significant issue whose occurrence threatens patient safety immensely. Their prevalence should be a sincere concern for health professionals who envision safe workplaces for patients and care providers. According to the U.S. Food and Drug Administration (FDA), approximately 100,000 cases of suspected medical errors are reported annually. The FDA (2019) further reported that medication errors have profound implications including disability, birth defects, and deaths. From personal experiences and observations, medication errors are preventable occurrences requiring multi-dimensional interventions to control effectively. They are preventable since they often occur due to human error, such as a lack of medication confirmation and failure to administer the correct dosage (Tariq et al., 2023). A multi-dimensional approach is necessary due to the differences in causes and the scope of the issue.
For effective outcomes, patients, health care professionals, and organizational leaders should play their individual roles effectively. For instance, leaders should provide appropriate education and technology for preventing medication errors as health professionals adopt them accordingly (Ahsani-Estahbanati et al., 2022; Rodziewicz et al., 2023). Patients should be adequately educated on the potential of medication errors, their prevention, and the importance of speaking up as members of the broader health care team. They should also provide health care professionals with adequate information about their health, current medications, and possible drug reactions to guide health professionals in the medication administration process.
The above information helps to explain medication errors from multiple perspectives, allowing the issue to be understood comprehensively. For instance, describing its prevalence underlines why it is a severe issue requiring maximum attention in health care settings. Besides, presenting it as a preventable health risk illustrates how human failure leads to its occurrence. The other information area is the need for a multifaceted approach involving different individuals and teams. Overall, this information can guide health care professionals and leaders to focus on the appropriate areas when formulating and implementing measures to prevent medication errors.
Analysis of the Issue
Definition
Although there is no standard definition of medication errors, various researchers, scholars, and organizations have provided several definitions to demonstrate what the issue entails. For instance, Rasool et al. (2020) defined a medication error as a failure in drug therapy, resulting in patient harm. Such harm includes health complications and disability. Tariq et al. (2023) expanded this definition by describing a medication error as a preventable event leading to inappropriate medication use. In any case, patient harm is inevitable, and its magnitude varies with the type of medication inappropriately used, the dosage, and the patient’s present health status.
Those Involved
Medication errors can occur in all settings where medication use is involved. Therefore, physicians, nurses, pharmacists could be involved in causing a medication error. Patients receiving inpatient or outpatient care can be victims of medication errors in varying magnitudes. Nursing research demonstrates that medication errors can occur at any stage of the medication process. These stages include medication prescription, transcription, dispensation, and administration (Schroers et al., 2021; Manias et al., 2020). Most errors are encountered during medication administration, hence increased attention in this area. Wondmieneh et al. (2020) reported that nurses are the most associated with medication errors since they spend over 40% of their time administering medications. Therefore, supporting them to execute their roles effectively is critical for medication error prevention.
Causes of Medication Errors
Understanding the causes of medication errors is the first step toward their effective control and management. Schroers et al. (2021) grouped the causes into knowledge-based, personal, and contextual factors. The most common knowledge-based cause is the lack of medication administration knowledge, particularly among new nurses. Personal factors include fatigue, while a heavy workload and interruptions dominate the contextual factors. Wondmieneh et al. (2020) reported that nurses’ failure to administer drugs at the scheduled time may cause patients to develop toxicities, hence, complications. Therefore, procedures to facilitate timely medication administration are vital for medication error prevention. Other causes include inappropriate prescribing and medication confirmation, a nursing shortage, and the absence of disease surveillance systems (Rasool et al., 2020). Several risk factors also increase the probability of medication error occurrence. They include old age, polypharmacy, and multiple comorbidities (Rasool et al., 2020). The impacts of medication errors vary with the cause, hence the need for an in-depth understanding of their origin and potential interventions.
Potential Solutions for the Issue
Medication errors solutions vary with the settings, causes, and manifestations. If the cause is errors in administrative procedures, interventions focused on improving medication administration should be prioritized. Reducing workload is crucial in settings where fatigue and high workloads cause medication errors (Schroers et al., 2021). The implication is that an in-depth understanding of the cause and potential interventions is crucial before implementing a solution. Common solutions include adopting technologies such as barcode scanning, education to prescribers, medication reconciliations, and appropriate use of electronic systems (Ahsani-Estahbanati et al., 2022; Schepel et al., 2019; Mulac et al., 2021). Each intervention has different outcomes, and effective implementation is essential to achieve the desired result. Barcode medication administration involves automating the verification process and helping nurses adhere to the five rights of medication administration (Mulac et al., 2021). Adopting this technology implies reducing medication administration errors, critical in reducing patient harm. However, barcode administration could be harmful if wrongly implemented due to the possibility of disrupting workflow and increasing workload (Mulac et al., 2021). Therefore, nurses should be appropriately educated on the technology use to optimize implementation results.
Ignoring the issue would have far-reaching implications since medication errors affect different groups of people directly and indirectly. The first group that experiences the adverse effects of medication errors is the patients. Rasool et al. (2020) reported that medication errors increase treatment costs, considering that they are the third leading cause of hospitalization after cardiovascular diseases and cancer. In the United States, medication errors are associated with more deaths than traffic accidents. Among nurses, medication errors intensify emotional and mental distress since they cause second-victim syndrome (Ozeke et al., 2019). The syndrome has similar effects to post-traumatic disorder and hampers nurses’ ability to concentrate on their work and offer patient-centered care. Organizational leaders are also affected due to the increased economic burden and workload and must adopt appropriate systems, policies, and cultures for medication error prevention.
Ethical Principles if Potential Solution was Implemented
Health care professionals should be innately committed to promoting ethical practice in their work settings. Achieving this role requires a commitment to addressing current and emerging issues hampering patient outcomes. To implement barcode medication administration, organizational leaders should be committed to change, supporting evidence-based interventions, and attaining a harmless workplace. For barcode scanning to work effectively, organizations should have functioning hardware to provide the appropriate preventive effect on errors (Mulac et al., 2021). As a result, acquiring the necessary infrastructure is essential for successful implementation. Organizational leaders should further ensure nursing professionals have acquired adequate skills for technology use to prevent user-centered risks. These interventions demonstrate a desire to benefit patients (beneficence) and prevent harm (nonmaleficence).
Ethical practice implies promoting a practice that adheres to the ethical principles of care. These include beneficence, nonmaleficence, autonomy, and justice (Medical Protection, 2023). Implementing barcode administration would align with the objectives of beneficence since it seeks to maximize good for others, particularly patients. Nonmaleficence would also be achieved since it focuses on preventing harm (Girdler et al., 2019). Autonomy involves respecting the patient’s right to self-determination, while justice involves treating patients equally and equitably. In this context, beneficence and nonmaleficence would be the dominant guiding principles when implementing barcode medication administration.
Conclusion
Nurses encounter many issues with profound implications for patient care and health processes. Medication errors are such issues due to their adverse impacts on patients, nurses, and health care systems. As explained in this paper, medication errors increase hospitalizations, treatment costs, and mortality rates. Nurses who commit errors could experience second-victim syndrome. Addressing this issue requires an in-depth understanding of causes and potential solutions. Barcode medication administration prevents errors through drug verification and can be implemented if a health care facility has the proper infrastructure to support it.
References
Ahsani-Estahbanati, E., Sergeevich Gordeev, V., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews. Frontiers in Medicine, 9, 875426. https://doi.org/10.3389/fmed.2022.875426
Individual patients and groups visit health care facilities looking forward to comprehensive care and continuous support from health professionals. A holistic assessment of health issues, appropriate treatment, and healthy patient-provider relationships characterize such care. Despite multiple efforts to achieve this goal, numerous issues that hamper patient safety and care quality occur at different care points. Accordingly, health care professionals and leaders should explore these issues and their implications and implement sustainable, evidence-based solutions. Evidence-based solutions are informed by current research to ensure they are valid (Alrabadi et al., 2021). The purpose of this paper is to analyze a current issue in health care, including a proposed solution and possible ethical implications.
Scholarly Information Explaining the Health Care Issue
Medication errors are a significant issue whose occurrence threatens patient safety immensely. Their prevalence should be a sincere concern for health professionals who envision safe workplaces for patients and care providers. According to the U.S. Food and Drug Administration (FDA), approximately 100,000 cases of suspected medical errors are reported annually. The FDA (2019) further reported that medication errors have profound implications including disability, birth defects, and deaths. From personal experiences and observations, medication errors are preventable occurrences requiring multi-dimensional interventions to control effectively. They are preventable since they often occur due to human error, such as a lack of medication confirmation and failure to administer the correct dosage (Tariq et al., 2023). A multi-dimensional approach is necessary due to the differences in causes and the scope of the issue.
For effective outcomes, patients, health care professionals, and organizational leaders should play their individual roles effectively. For instance, leaders should provide appropriate education and technology for preventing medication errors as health professionals adopt them accordingly (Ahsani-Estahbanati et al., 2022; Rodziewicz et al., 2023). Patients should be adequately educated on the potential of medication errors, their prevention, and the importance of speaking up as members of the broader health care team. They should also provide health care professionals with adequate information about their health, current medications, and possible drug reactions to guide health professionals in the medication administration process.
The above information helps to explain medication errors from multiple perspectives, allowing the issue to be understood comprehensively. For instance, describing its prevalence underlines why it is a severe issue requiring maximum attention in health care settings. Besides, presenting it as a preventable health risk illustrates how human failure leads to its occurrence. The other information area is the need for a multifaceted approach involving different individuals and teams. Overall, this information can guide health care professionals and leaders to focus on the appropriate areas when formulating and implementing measures to prevent medication errors.
Analysis of the Issue
Definition
Although there is no standard definition of medication errors, various researchers, scholars, and organizations have provided several definitions to demonstrate what the issue entails. For instance, Rasool et al. (2020) defined a medication error as a failure in drug therapy, resulting in patient harm. Such harm includes health complications and disability. Tariq et al. (2023) expanded this definition by describing a medication error as a preventable event leading to inappropriate medication use. In any case, patient harm is inevitable, and its magnitude varies with the type of medication inappropriately used, the dosage, and the patient’s present health status.
Those Involved
Medication errors can occur in all settings where medication use is involved. Therefore, physicians, nurses, pharmacists could be involved in causing a medication error. Patients receiving inpatient or outpatient care can be victims of medication errors in varying magnitudes. Nursing research demonstrates that medication errors can occur at any stage of the medication process. These stages include medication prescription, transcription, dispensation, and administration (Schroers et al., 2021; Manias et al., 2020). Most errors are encountered during medication administration, hence increased attention in this area. Wondmieneh et al. (2020) reported that nurses are the most associated with medication errors since they spend over 40% of their time administering medications. Therefore, supporting them to execute their roles effectively is critical for medication error prevention.
Causes of Medication Errors
Understanding the causes of medication errors is the first step toward their effective control and management. Schroers et al. (2021) grouped the causes into knowledge-based, personal, and contextual factors. The most common knowledge-based cause is the lack of medication administration knowledge, particularly among new nurses. Personal factors include fatigue, while a heavy workload and interruptions dominate the contextual factors. Wondmieneh et al. (2020) reported that nurses’ failure to administer drugs at the scheduled time may cause patients to develop toxicities, hence, complications. Therefore, procedures to facilitate timely medication administration are vital for medication error prevention. Other causes include inappropriate prescribing and medication confirmation, a nursing shortage, and the absence of disease surveillance systems (Rasool et al., 2020). Several risk factors also increase the probability of medication error occurrence. They include old age, polypharmacy, and multiple comorbidities (Rasool et al., 2020). The impacts of medication errors vary with the cause, hence the need for an in-depth understanding of their origin and potential interventions.
Potential Solutions for the Issue
Medication errors solutions vary with the settings, causes, and manifestations. If the cause is errors in administrative procedures, interventions focused on improving medication administration should be prioritized. Reducing workload is crucial in settings where fatigue and high workloads cause medication errors (Schroers et al., 2021). The implication is that an in-depth understanding of the cause and potential interventions is crucial before implementing a solution. Common solutions include adopting technologies such as barcode scanning, education to prescribers, medication reconciliations, and appropriate use of electronic systems (Ahsani-Estahbanati et al., 2022; Schepel et al., 2019; Mulac et al., 2021). Each intervention has different outcomes, and effective implementation is essential to achieve the desired result. Barcode medication administration involves automating the verification process and helping nurses adhere to the five rights of medication administration (Mulac et al., 2021). Adopting this technology implies reducing medication administration errors, critical in reducing patient harm. However, barcode administration could be harmful if wrongly implemented due to the possibility of disrupting workflow and increasing workload (Mulac et al., 2021). Therefore, nurses should be appropriately educated on the technology use to optimize implementation results.
Ignoring the issue would have far-reaching implications since medication errors affect different groups of people directly and indirectly. The first group that experiences the adverse effects of medication errors is the patients. Rasool et al. (2020) reported that medication errors increase treatment costs, considering that they are the third leading cause of hospitalization after cardiovascular diseases and cancer. In the United States, medication errors are associated with more deaths than traffic accidents. Among nurses, medication errors intensify emotional and mental distress since they cause second-victim syndrome (Ozeke et al., 2019). The syndrome has similar effects to post-traumatic disorder and hampers nurses’ ability to concentrate on their work and offer patient-centered care. Organizational leaders are also affected due to the increased economic burden and workload and must adopt appropriate systems, policies, and cultures for medication error prevention.
Ethical Principles if Potential Solution was Implemented
Health care professionals should be innately committed to promoting ethical practice in their work settings. Achieving this role requires a commitment to addressing current and emerging issues hampering patient outcomes. To implement barcode medication administration, organizational leaders should be committed to change, supporting evidence-based interventions, and attaining a harmless workplace. For barcode scanning to work effectively, organizations should have functioning hardware to provide the appropriate preventive effect on errors (Mulac et al., 2021). As a result, acquiring the necessary infrastructure is essential for successful implementation. Organizational leaders should further ensure nursing professionals have acquired adequate skills for technology use to prevent user-centered risks. These interventions demonstrate a desire to benefit patients (beneficence) and prevent harm (nonmaleficence).
Ethical practice implies promoting a practice that adheres to the ethical principles of care. These include beneficence, nonmaleficence, autonomy, and justice (Medical Protection, 2023). Implementing barcode administration would align with the objectives of beneficence since it seeks to maximize good for others, particularly patients. Nonmaleficence would also be achieved since it focuses on preventing harm (Girdler et al., 2019). Autonomy involves respecting the patient’s right to self-determination, while justice involves treating patients equally and equitably. In this context, beneficence and nonmaleficence would be the dominant guiding principles when implementing barcode medication administration.
Conclusion
Nurses encounter many issues with profound implications for patient care and health processes. Medication errors are such issues due to their adverse impacts on patients, nurses, and health care systems. As explained in this paper, medication errors increase hospitalizations, treatment costs, and mortality rates. Nurses who commit errors could experience second-victim syndrome. Addressing this issue requires an in-depth understanding of causes and potential solutions. Barcode medication administration prevents errors through drug verification and can be implemented if a health care facility has the proper infrastructure to support it.
References
Ahsani-Estahbanati, E., Sergeevich Gordeev, V., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews. Frontiers in Medicine, 9, 875426. https://doi.org/10.3389/fmed.2022.875426