Causes and interventions of medication errors in healthcare facilities
Authors:
Jan Neugebauer; Valérie Tóthová; Ivana Chloubová; Hana Hajduchová; Iva Brabcová; Radka Prokešová
Authors‘ workplace:
Zdravotně sociální fakulta, Jihočeská univerzita v Českých Budějovicích
Published in:
Čes. slov. Farm., 2021; 70, 43-50
Category:
Original Article
doi:
https://doi.org/10.5817/CSF2021-2-43
Overview
A medication error is one of the most common causes of patients’ complications or death in healthcare facilities. In the United States, 7,000 out of 9,000 patients die because of medication errors each year. Known factors are generally divided into four groups – human factor, intervention, technical factor, and system.
Our study includes 17 studies from the OVID, Web of Science, Scopus, and EBSCO databases, in the range of 2015–2020. After a selection of professional publications, 2 categories were created – factors leading to medication errors and interventions to reduce medication error and testing their effectiveness.
It has been found that human factor always plays a role, often supported by a poorly set-up system. The most mistakes are made in documentation, administration technique or accidental interchange of patients. The most frequently mentioned factors include nurses’ overload, high number of critically ill patients, interruptions in the preparation or in the administration of medications, absence of the adverse event reporting system, non-compliance with guidelines, fear, and anxiety.
Another evidence of medication error is in the application of intravenous drugs, where an interchange of drugs or patients due to interruption occurs as well. Sufficient education of nurses and an adequate system of preparation and administration of drugs, for example using bar codes, are considered as an appropriate intervention.
Keywords:
medication error – drug preparation – Drug administration – factors of medication error – intervention
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