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Medication error - Essay Example

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Fixing the System to Fix Errors: Causes of and Solutions to Medication Errors Name University June 26, 2013 Abstract This paper examined the causes of and solutions to medication errors. Human, environmental, and organizational factors cause medication mistakes, but a number of important environmental and system-based changes can be made to decrease the risks and instances of medication errors…
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Download file to see previous pages Quality management philosophies and systems are highlighted because they emphasize a learning organization culture that critically determines and resolves medication errors in the long run. Hence, medication errors are not the responsibility of prescribers alone, but a responsibility of the healthcare team and the healthcare organization, as well as the government. Introduction On September 14, 2010, 50-year-old Kimberly Hiatt, a longtime critical care nurse at Seattle Children’s Hospital, administered the wrong dosage of calcium to a fragile baby, Kaia Zautner (Aleccia, 2011). Zautner died five days later, although it was not clear whether the medication error killed her. Nevertheless, Hiatt, who was fired and underwent a state nursing commission investigation, committed suicide seven months after Zautner died. Aleccia (2011) reported that around 1 in 7 Medicare patients are harmed because of medication errors. Andel et al. (2012) estimated the economic costs of medication errors using quality-adjusted life years (QALYs) and the Institute of Medicine’s report of 98,000 deaths every year. They discovered that the conservative cost of these deaths is “$73.5 billion to $98 billion in QALYs” (Andel et al., 2012, p.41). ...
Causes of Medication Errors: Providers and Environment Tully et al. (2009) examined the causes of and factors connected to medication errors that concern prescriptions for hospital inpatients. They grouped the causes according to Reason’s model of accident causation, which will also be used in this essay: active failures, error-provoking conditions and latent conditions. Active Failures Active failures pertain to hazardous acts that prescribers make, which means that all medication errors consist of at least one active failure (Tully et al., 2009, p.826). One of the most common sources of active failure is knowledge-based. Prescribers committed mistakes either because they did not know enough about the drug or about the patient (Grissinger & Kelly, 2005, p.62; Tully et al., 2009, p.826). Some of the examples are giving the wrong dose or not being aware that a patient’s co-morbidity was a contraindication for the provided medicine. Another kind of active failure is skill-based or based on memory lapses (Tully et al., 2009, p.826). A couple of instances are interruption of the prescriber, who then makes a mistake, and when prescribers were too busy that they made an error. Aside from skill-based faults, policy violations are also problematic. Violations refer to active choices wherein prescribers ignore formal or informal policies that they were expected to follow (Tully et al., 2009, p.826). One example is medication error that comes from a medical student because his supervisor did not check his prescription. These active failures contribute to numerous medication errors. Error-provoking Conditions Error-provoking conditions are different from active ...Download file to see next pagesRead More
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