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Medication errors continue being a major cause for
concern among the nursing profession. While many efforts have been put forth to
eradicate this preventable cause of patient harm, the incidence of medication
errors still continues to climb. According to an article in American Nurse
Today (2015), “medication errors account for more than seven thousand deaths
annually and each error cost anywhere from $2,000 to $8,750 dollars” (Anderson, & Townsend, p.
18). This statistic is alarming and does not even consider the medication
errors that go unreported. Doctors, nurses and pharmacist play a vital role in catching
and preventing these errors. Along with research, I was able to have a face to
face interview with Ademola Adekunle, PharmD, a pharmacist at Texas Health Resources
in regard to preventing medication errors, our policy on reporting errors, and
methods to promote reporting.  

Preventing Medication Errors

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Multiple factors contribute to the cause of medication errors.
Errors can occur at any stage of medication management, ranging from
prescription, preparation, and administration. For this reason, it is essential that everyone
involved in the medication cycle be aware of prevention methods used to reduce
the occurrence of error. One critical tool in preventing medication errors, is using
the five rights to medication administration and barcode scanning. These tools
help make sure the right medication at the right time is going to the right
patient. Ademola explained the benefits to computer ordering versus handwritten
orders. “Being able to obtain orders through the computer has help tremendously
in reducing errors due to handwriting that is difficult to read” (Adekunle,
personal communication, January 15, 2018). According to a study held by Kumas,
Madhwar, Pathak, & Saiki (2016), transcription related errors were 72.4 per
month and drastically dropped to 2.2 per month after applying the Computerized
Physician Order Entry (CPOE) tool (p. 1003). Finally, Ademola and I talked
about the significance of correctly labeling look alike medications to help
avoid confusion.

Error Reporting

facilities have a policy in regard to reporting medication errors. By reporting
these errors, mistakes can be explored and prevented in the future. According
to the World Health Organization (2014), “Although each event is unique, there are likely to be similarities
and patterns in sources of risk which may otherwise go unnoticed if incidents
are not reported and analyzed” (p. 7). The facility that I work for uses the
Reliability Learning Tool (RLT) in the case of reporting medication errors. The
RLT is an online detailed form describing the medication error. The form ranges
from information on the nurse, patient, medication involved, equipment
involved, others present, and more. The tool has been proven to be very effective
when used.

to Encourage Reporting Medication Errors

            It is imperative that nurses are knowledgeable about the
importance of reporting both potential and actual medication errors. Reporting
medication errors was unintended to punish the error maker, but to help recognize
mistakes and find ways to prevent future errors. “In order to increase
reporting, it is essential nurses are supported during the reporting process” (Kavanagh, 2017, p. 162). Ademola
stated, “I feel like many staff do not use the RLT in fear of getting in
trouble for making the error and also because they are unaware of the purpose
of the tool” (Adekunle, personal communication, January 15, 2018). Assisting
staff with more education on using the RLT and the purpose will help increase


conclusion, it is vital that medication errors are identified and interventions
set in place to improve patient safety. By using the Reliability Learning Tool
to report medication errors, safety teams can identify was to improve and
prevent future errors. Anyone involved in the management of a patient’s
medication should use the various tools presented to help reduce error and
improve patient safety. 

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