Introduction
One of the most significant patient safety concerns that span across all stages of care is medication mistakes. Such errors ultimately affect millions of patients, involving billions lost annually to the United States in unnecessary treatment, readmissions, and loss of productivity. Medication errors most often occur as a result of system failure and breakdowns rather than from being reckless. Improvement in interdisciplinary collaboration, evidence-based quality improvement initiatives, and redesigned broken systems present significant opportunities for better patient results as well as reduce needless costs due to medication errors. This report will also discuss the common risk factors that predispose patients to medication errors, define evidence-based solutions to reduce risks, describe nursing roles in coordinating safe med use throughout the care pathway, and identify vital stakeholders nurses must partner with for sustainable safety improvements.
Factors Leading to Medication Errors
However, several factors may predispose patients to medication errors. Poor handwriting or information not included on the prescription forms of written prescriptions and medication orders can cause mistakes in drug selection, dose, route, or frequency. In the case of misinterpretation, orders can also be wrongly credited to providers. Non-standard, inaccurate, or incomplete orders require nurses and pharmacists to make an assumption that often leads them to a wrong interpretation. Also, most of the drugs are spelled and pronounced in a similar manner, which can lead to confusion. For instance, Celebrex and Cerebyx – the first is an arthritis drug; the second one treats seizures. Selecting the wrong choice during ordering or administration leads to patient harm.
Furthermore, physicians usually prescribe by brand name; the pharmacy dispenses with generics per hospital protocols. When the medication they receive does not look as it is supposed to, patients get confused. Patient duplication of therapy or doses missed has been due to poor healthcare team communication regarding authorized generic swapping. There is also a significant risk of erroneous dosing based on patient weight, renal function, or other parameters leading to either sub-therapeutic or toxic effects. Complexity and rate of medication errors grow even further due to the added teddy bear requirements in pediatric patients as well as NICU micro drip calculations.
In addition, patients might not fully comprehend what medications they are taking and how to take them appropriately without side effects or adverse events that should be monitored because there were no instructions upon discharge, and teach-back was never confirmed. Patients’ safety is compromised during post-hospitalization owing to knowledge gaps that lead to non-adherence or self-discontinuation. There is also usually broken communication between providers in the hospital, nurses, retail pharmacies, and follow-up services that complicate fluid medication access. The absence of solid reconciliation and follow-up processes during care transitions results in patient medication changes being lost, which causes adverse drug events (Dellogono et al., 2020).
Evidence-Based Solutions for Medication Safety
Some of the evidence-based ways in which health systems can address medication safety issues include electronic prescribing and computerized provider order entry that helps eliminate illegibility while providing default options/dosing ranges to guide the complete ordering process and increase clarity. It also removes replications and drug side effects, improving safety through alerts and warnings. Barcode medication administration with ID band scanning and coupled medications is another safeguard against errors by verifying the five rights, including the right drug, dose, and patient route time before administration (Heikkinen, 2022).
Also, pharmacists play a critical role in the verification and identification of therapeutic duplication or interactions, as well as recommendations for appropriate drug substitution based on the latest evidence that guides provider prescribing. Computerized clinical decision support systems (CDSS) provide real-time computer prompts at order entry to reduce the risk of reactions or contraindications and suggest alternatives through algorithmic advisories and alerts by preventing continuation or reordering of medications that were discontinued, standardized medication reconciliation processes upon admission and at the time of discharge decreases drug safety during care transitions. Increasing the transfer of accurate medication histories between care teams leads to lower risks due to communication-based prescribing errors and adverse events (Zeng et al., 2022).
Nursing Roles in Care Coordination and Safety
Nurses are crucial in integrating care across settings to ensure medication security. When admitting and discharging patients, nurses ask them to provide detailed medication records about all the medications that they are using at home, including their doses and frequencies. Allowed list comparison with new inpatient regimens contributes to reconciliation and, thus, reduces unintentional duplication or omission of needed therapies (Hung et al., 2021). Nurses also collaborate closely with providers and pharmacy personnel through accurate-order transcription verification, passing on alternatives for unavailable meds formulary suggestions, as well as immediate reporting or documentation around missed or delayed medication dosage that would cause a patient any harm.
Furthermore, nurses implemented plain language and teach-back education techniques to adequately instruct patients as well as family members concerning the reason for use, appropriate administration, storage monitoring adverse effects, and compliance tips at discharge medications. Reinforcing this medication teaching, as well as answering patients’/caregivers’ questions before release, provides continuity of accurate medication utilization to improve their safety in the ambulatory setting. Thus, nursing coordination acts as the communication nexus in interdisciplinary teams, care transition personnel, and patients’ families that promote seamless medication access education while allowing monitoring of patients for better, safer, and effective use.
Conclusion
In conclusion, errors made due to illegibility, confusion, miscalculation, and poor coordination pose significant patient safety threats associated with costly ramifications. Appropriate interventions that are collaborative and evidence-based involving e-prescribing, barcode scanning, and pharmacist reviews reconciliation process can significantly improve accuracy as well, and it takes extensive coordination among providers, pharmacy, patients and their families, transition staff, and IT to alleviate the risks associated with medication through nurses. Just culture facilitates a frank conversation about the weaknesses with a healthy dose of collective responsibility in ensuring that deficient systems responsible for setting up conditions favorable to human errors are effectively redesigned.
References
Dellogono, A., Dawson, A., Piers-Gamble, M., Varghese, J., & Lewicki, L. (2020). Lost in transition: pharmacist roles in identifying and evaluating medication-related problems during hospital discharge follow-up visits in a primary care setting. Journal of Primary Care & Community Health, 11, 2150132720917297.
Heikkinen, I. (2022). Barcode Medication Administration and Patient Safety: A narrative literature review.
Hung, P. L., Lin, P. C., Chen, J. Y., Chen, M. T., Chou, M. Y., Huang, W. C., … & Lin, A. C. (2021). Developing an integrated electronic medication reconciliation platform and evaluating its effects on preventing potential duplicated medications and reducing 30-day medication-related hospital revisits for inpatients. Journal of Medical Systems, 45, 1-12.
Zheng, F., Wang, D., & Zhang, X. (2022). The impact of clinical pharmacist-physician communication on reducing drug-related problems: a mixed study design in a tertiary teaching Hospital in Xinjiang, China. BMC Health Services Research, 22(1), 1-11.
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