NHS-FPX4000 Assessment 3-1 Assessment : u03a1: Analyzing a Current Health Care Problem or Issue

NHS-FPX4000 Assessment 3-1 Assessment : u03a1: Analyzing a Current Health Care Problem or Issue

Analyzing Medication Errors
Medication administration safety is very important in health care and is increasingly
worsening, as discussed in assessment two. Medication errors kill 7,000 to 9,000 people yearly,
just in the United States (Tariq et al., 2020). Health care organizations should develop systems to
ensure safe medication administration.
Elements of Medication Errors
Medication errors may be caused by a various amount of factors. One of these factors is
look-alike/sound-alike (LASA) medications (Rash-Foanio et al., 2017). There are thousands of
medications and many of these medications have similar names. This can cause an error if the
prescriber is overwhelmed or busy. The example that the authors of American Journal of Health-
System Pharmacy used was the similarity between cycloserine and cyclosporine. The prescriber
ordered cycloserine but cyclosporine was the medication they meant to prescribe.
Most medication errors occur during the ordering process. Ordering errors account for about half
of the medication errors. About 70% of these ordering errors are identified by either nurses or
pharmacists. About 75% of prescribing errors are related to distractions in the work place.
Prescribers may be bombarded by several nurses wanting medications for their patients, this
causes many distractions (Tariq et al., 2020).
Another contributor to mediation errors are whether safety checks are carried out. There
are a few departments where safety checks are not carried out. These units usually include
emergency care. One other department where medication errors are common, is the surgery
department, including perioperative care, operative care and postoperative care. In these units,
there are a few instances where a medication error may occur. These instances are, stress, time-

sensitive, incomplete order sets of medications and there is not scanning barcodes before
administering medications (Nanji, Patel, Shaikh, Seger, & Bates, 2016).
Analysis of Medication Errors
Medication errors can be very dangerous. I was given a medication I was allergic to
because the nurse did not check my allergies and scan the medication before giving it to me.
Because she did not follow her safety checks, I stopped breathing and she had to give me Narcan
to counteract the opioid. Since this incident, I have always been careful when giving medications
to patients as I am a nurse now as well.
Context for Medication Errors
Health care personnel are becoming overworked. The nurse to patient ratio are increasing
along with less and less doctors around to care for patients. This causes health care personnel to
have a high patient load. Along with this, they are expected to chart everything and be done with
their tasks in a short time frame. This adds more stress and as the provider rushes to get the
medication orders in for their many patients, or the nurse is on her eighth med pass of the
morning, it can be the perfect storm for a medication error to take place (Tariq et al., 2020).
Populations for Medication Errors
Medication errors can affect anyone of any age. Medication errors in the pediatric
population is more dangerous than the adult population. Pediatric doses are weight based. Weight
based dosing involves a decent amount of math. In the United States, we measure weight by
pounds. However, weight has to be converted to kilograms from pounds to calculate the dose.
Medication errors with pediatric clients are using a math error, and usually with liquid
medication. A small medication error in a child in much more severe than in an adult (Geneva:
World Health Organization, 2016)

Another common age for medication errors is the elderly. They usually have a couple
health complications and if their providers are not attentive, they may prescribe something that
contraindicates with another medication they are on. The elderly also may take medications other
than how it is advised on the prescription label (Geneva: World Health Organization, 2016).
They may not understand the frequency of the medication. Such as if it says as needed. It is hard
to know whether it is as needed every few hours or once daily.
Solutions for Medication Errors
Medication errors can be eliminated for the most part as long as safety measures and
steps are taken. First of, the medication room should be a quiet zone. Making the medication
room a quiet zone, this eliminates noise that could be distracting to eliminate someone grabbing
the wrong medication for a patient (Tariq et al., 2020). Secondly, the nurses should be verifying
the medications they are grabbing with the patient’s electronic medical record (EMR). Next, the
nurse should verify with the patient any allergies they have, making sure there are no allergies to
the medication they have to give the patient. Lastly, when the nurse takes the medications to the
patient, they should scan the patient’s armband and then the medication to verify before
administering the medication.
Implementing the Solutions
Although, these steps may cause nurses to spend more time with medication passes, it
ensures the safety of the patients. In order to implement these solutions there are a few items
needed. Signs implementing a quiet zone should be placed inside and outside the medication
room. A computer should also be placed near the medications in the medication room for the
nurses to pull up the patient EMR to verify medications and dosing (Tariq et al., 2020). Barcode
scanners should also be hooked up to each computer in the patient rooms or there should be