Medication Error Prevention
Section 1: Identify
- Describe your assigned topic and why it is a concern in healthcare.
- Summarize a current policy or procedure at your facility related to this issue. How is this issue currently addressed?
- What inconsistencies exist between your facility’s current policies, actual nursing practice, and best evidence related to your assigned topic? What evidence (data, observation, incident reports) suggests a need for improvement?
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Medication Error Prevention
Description and Concern in Healthcare
Medication errors are a major concern in healthcare because they can lead to adverse drug events, patient harm, increased hospital stays, and even fatalities. These errors may occur at any stage—from prescribing to administration. Inaccurate dosages, wrong medications, or overlooked allergies are common causes. Preventing medication errors is crucial for patient safety, regulatory compliance, and maintaining trust in healthcare systems. This is a high-priority patient safety issue globally.
Current Facility Policy
At my facility, the current policy emphasizes the “Five Rights” of medication administration: right patient, right drug, right dose, right route, and right time. Nurses must use electronic medical records (EMR) and barcode scanning to verify medications before administration. Staff are trained during onboarding and receive annual competency evaluations. Incident reports must be completed for any error or near miss, and these are reviewed by the quality improvement committee.
Inconsistencies in Policy and Practice
While policies are clear, inconsistencies arise in practice. Some nurses bypass barcode scanning due to time pressures, especially in emergencies. Best evidence supports full adherence to safety protocols, yet workflow challenges sometimes hinder compliance.
Evidence Suggesting Improvement Needs
Incident reports show a steady number of near misses related to look-alike or sound-alike drugs. Observations during audits reveal skipped scanning steps and inconsistent documentation. Data from the quality improvement team highlight higher error rates during night shifts and peak patient admissions. These findings indicate the need for reinforcing barcode scanning compliance, improving workflow efficiency, and enhancing staff education to close the gap between policy and practice.
