Annotated Bibliography

Preventable medical mistakes cause approximately 200,000 deaths around the United States each year. (1) More than 1,000,000 Americans are negatively impacted by medication errors each year caused by inadvertent mistakes in the prescription filling process. With 4 out of 5 adults taking at least 1 medication daily and 1 out of 4 adults taking 5 or more medications daily nationwide, errors like these cost healthcare industry billions of dollars per year. Health information technology were developed to transform healthcare services, the way they are provided and compensated. Electronic prescribing (e-prescribing) becomes an internal part of that transformation process, which can be confirmed from annual Surescripts’ National Progress Report.

Most of us probably cannot recall a world without internet, cellphones, and laptops. Technology has transformed the world we live in today. Undoubtedly, technology has changed the way health care is delivered. Electronic prescribing allows prescribers to send prescriptions electronically and directly to the pharmacy. E-prescribing has been demonstrated to reduce prescribing errors in outpatient settings.

According to estimates, at least 1.5 million preventable medication errors and adverse drug events occur each year in the United States. One-third of all medication errors occur during the administration phase of medication delivery (Durham, 2015). Medication safety is freedom from preventable harm with medication use; therefore, nurses must promote patient safety by understanding their contributions to the prevention of medication error (Choo, Hutchinson, & Bucknall, 2010). Additionally, a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional. Thus, to promote medication safety, nurses must understand their roles in proper medication management and identify challenges that associated with medication safety.

Reporting medication errors is beneficial to improve the learning process for nurses. The factors of workload, ineffective communication, and distraction all contribute to medication errors (Sears et al., 2013). Nurses often excuse the behavior of colleagues when a medication error occurs, or nurses will pass the buck to a senior nurse to report the medication error (Haw, Stubbs and Dickens, 2014). Implementing a no blame policy for reporting medication errors, and providing nurses with the knowledge and training to report medication errors will result in an increase of medication errors reported. References Haw, C., Stubbs, J. and Dickens, G. (2014).

With increasing the acceptance of using e-prescribing in health care , evaluating and understanding the types of e-prescribing errors can help to identify the prober ways to prevent future e-prescription errors from reaching patients. It is also important to use health information technology to improve safety, such as use of technology to identify and monitor patient safety events, risks and hazards ;and to intervene before actual harm occurs

During treatment, there are numerous people with various types of health-care providers including doctors, nurses, pharmacists, social workers and several more involved in handling the patient,(Who.int,2015).Therefore, there is an increased difficulty in ensuring safe care, unless there is an effective system designed to facilitate any general probable issues.(Who.int,2015). Thus, harmful effects can arise from problems within the practice, with the products, the procedures or the systems. Patient safety therefore demands an intricate system wide effort which involves a wide range of actions surrounding performance improvement, environmental safety and proper risk management which focuses on infection control, the safe use and handling of medicines, equipment safety and creating a safe clinical environment to care for the

Chloe Copping (RGN) published an article titled ‘Preventing and reporting drug administration errors. In this article she suggests that the most common source of drug administration errors are within calculation and also the 5 R’s, right drug, right route, right time, right dose and right patient. She states that a busy working environment can lead to distraction which then leads to medication errors therefore inhibiting patient safety. To overcome this problem she recommends that “good communication, clarity and vigilance are vital whenever drugs are being administered”. After drugs have been administered patients should be observed to ensure that they are not having undesirable reactions to the medication.

One significant barrier is the potential detrimental impact on physician and staff workflow. Computer-based systems that allow clinicians to prescribe drugs electronically are designed to automatically warn of potential medication errors, but a new study reveals clinicians often override the alerts and rely instead on their own judgment. A study, at Dana-Farber Cancer Institute showed that most clinicians find the current medication alerts a task of annoyance rather than a valuable tool for patient safety. Although the e-prescribing alert with improve medication safety, we the society will not see its benefit until there is a system to help clinicians better manage medication safety alerts. This study shed a light on the real value of e-prescribing alerts in the eyes of our clinicians.

The studies reviewed are: Medication errors: classification of seriousness, type, and of medications involved in the reports from a University Teaching Hospital (Dalmolin, Rotta, & Goldim, 2013), Types and causes of medication errors from nurse 's viewpoint (Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013), and Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence (Keers, Williams, Cooke, & Ashcroft, 2013). The remaining data reviewed consisted of peer reviewed articles, they were the following: The Effect of a Safe Zone on Nurse Interruptions, Distractions, and Medication Administration Errors (Yoder, Schadewald, & Dietrich, 2015), Celebrating Human Resilience to Provide Safe Care (Moffett & Moore, 2011), and A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses ' Roles in Practice (Sherwood & Zomorodi,

Recognizing, acknowledging, and understanding medication safety is important when administering medications. Understanding which medications are high-risk ones, being familiar with the medications being given, remembering the five most important rights when administering medications, communicating clearly, developing checking habits, and reporting the medication errors will lead to safe outcomes for the residents. However, errors do occur from a lack of experience, rushing, distractions, fatigue, doing too many things at once, not double checking, poor communication, and lack of team work. It is not only the staff that commit errors, but also the work environment that contributes to the medication error. Two examples are poor reporting systems

However, errors still exist at the dispensing and administration levels. These errors can also be further significantly reduced with the implementation of additional resources and functions. There are system flaws and human error factors to take into account. Many errors occur due to incorrect drug formularies, outdated protocols and order sets, nonstandard terminology, lack of standards for alerts and warnings, and too many steps to complete tasks have also been

Medication Errors in Healthcare The nursing profession entails many responsibilities that range from providing emotional support to administering medications that could result in death for those receiving care. Approximately 40% of a nurse's day consists of passing medication, a duty that sets their level of liability above many other healthcare professions (McCuistion, Vuljoin-DiMaggio, Winton, Yeager, & Kee, 2018). Despite today's advances in technology and nursing education, the frequency of medication errors is still staggering. To ensure that the benefits of nursing outweigh the risks, nurses look to the Quality and Safety Education for Nurses (QSEN) six core competencies for guidance.

the order being suspended/ changed, dose adjusted, the medication is out of the designated time frame, and/or the pharmacy loaded the wrong medication or dosage into the Omnicell (medication dispenser). There are a series of cause-and-effect scenarios the nurse must play out to resolve the discrepancy. Therefore, “informatics can enhance thinking, but thinking is also a requisite to the effective use of informatics” (Rubenfeld and Scheffer, 2015, p.

Error-free medication process may be a challenge; but not impossible; medication incidents decrease from 31.2% to 14.3% during the five years in 2009-2013(al-Faouri, Hayajneh, Habboush, 2014). Keer et al. ,2015, describe medication error in mental health as a prescribing errors (20.8%) related to decision or writing process, including prescribing a drug without appropriate monitoring service (e.g. Clozapine) and prescribing drug treatment without authorization from a Mental Health Act or clerical errors (71.9%), and errors involving inadequate communication of medicines ( 68.8 %) stopped during admission. Additionally; Ayani et al., found 29 % of medication errors were classified as serious or

Patient care and treatment is a complex process that involves several members of the healthcare team who work together with the patient towards a common goal. Because of this, medication errors can happen in any of these steps in the treatment