According to Wondmieneh et al. (2020), unsafe medication administration errors are the leading causes of preventable adverse health outcomes in patients, such as disability and death. They also affect health professionals and health organizations and can lead to forfeiture of practice licensing and criminal liability. Reducing and preventing medication errors is complicated, but it is necessary to improve patient safety (Tariq et al., 2021). It is important to carry out a root-cause analysis (RCA) to identify the causes of errors and elements essential to prevent such errors, improve patient safety, and reduce errors associated with medication administration. An RCA in healthcare is a problem-solving technique that aims to identify and understand the root causes of errors and other issues and how to fix them (Martin-Delgado et al., 2020).
The nurse manager identified 18 incidents of reported MAEs in the inpatient facility in the last six months. Considering the threat of medication administration errors on patient safety and the overall consequences of such errors to the clinicians and the facility, an RCA was conducted on the reported errors to identify their root causes. It was identified that all cases were reported by nurses who had administered medication to in-hospital patients. Ninety-two percent of the cases were directly caused by errors from the nurses’ side, while eight percent of the cases resulted from patient faults.
The RCA on causes of medication administration errors noted that 42 percent of the errors resulted from a lack of knowledge of drug information, including drug-to-drug interactions and drug action. In addition, 26 percent resulted from a lack of adequate communication with physicians, while 17 percent resulted from wrong medication calculations leading to wrong dosages. Eight percent of the reported cases were due to administering medications to the wrong patient. Three percent were linked to distraction and stress during the administration. Two percent were due to the patients moving during intravenous administration, leading to the errors, while 2 percent were due to administering the right medication using the wrong route.
Only eight percent of the reported errors resulted in patient harm while 92 percent did not cause any adverse drug outcomes; however, they have the capacity to compromise patient safety within the facility. Due to the clinical equation of errors to duty failure, the fear of associated punishment and legal action, and other associated consequences, a clinician may be reluctant to report errors (Rodziewicz et al., 2018). This means that the reported medication administration errors do not represent the actual number of errors occurring within the inpatient facility. The uncertainty of errors occurring getting reported creates a need to develop targeted, evidence-based initiatives to improve the safety and quality of medication processes and prevent medication administration errors.
According to the RCA, a majority of errors result from a lack of knowledge of drug information, including drug-to-drug interactions and drug action. The lack of adequate communication with physicians was also noted as a major cause for concern in medication administration safety. The RCA noted that nurses are central in the occurrence and prevention of medication administration errors.
Wondmieneh et al. (2020) concluded that nurses were more likely to cause medication errors due to failure to follow guidelines, work experience, interruptions from patients, and other environmental factors. Escrivá Gracia et al. (2019) linked the drug-knowledge gap to such errors, while Tariq et al. (2021) related MAEs to incorrect dosage, dose preparation, timing, and lack of information on interactions and contraindications.
Research on medication safety has identified various evidence-based strategies to prevent MAEs. Improving drug knowledge among transcribers and using assistive technology during drug administration have been identified as major evidence-based strategies for preventing medication administration errors. The improvement of communication has also been noted to improve the quality of medication administration. Wondmieneh et al. (2020) suggested training nurses and providing clear guidelines to nurses. Rozenblum et al. (2020) identified that the use of machine learning systems in medication administration could help identify and prevent medication errors and impact patient safety.
The RCA identified the major cause of mediation administration errors in in-patient care as majorly r
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