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Client Safety, Risk Management, and Innovation Assignment

Student Name- Navpreet Kaur

Student No. – N01588957

Institution – Humber College North Campus

Course- NURS-218 OND

Professor- Karen Goodwin

Due Date- October 10, 2023

Introduction

Medication mistakes have the potential to happen at any point during the medication

usage and the medication usage process can be avoided. They are widespread in the

healthcare system and are linked to an increased risk of morbidity and mortality (Jaam et al.,

2021). Pharmacists play a vital role in global healthcare settings as they operate with other

healthcare professionals to ensure optimal care, improved health outcomes, and medication

safety. Patient safety is the main priority in universal healthcare. Along the medication

pathway, medication dispensing and preparations are the most common processes that

involve the services of a pharmacist, thus making the pharmacist's role a useful consideration.

The pharmacist can contribute greatly to medication errors by encountering errors in drug

preparations, drug-to-drug interactions, overprescription, or the inappropriate delivery of

opioids. Anyone irrespective of age, gender, and diagnosis can be affected by medication

errors in healthcare settings which is the main source of mortality and morbidity, when

unresolved and undetected, lengthening hospital stays thus driving huge costs in the

healthcare systems. Hence, the literature review assesses the pharmacist's role relative to

medication errors, thus offering recommendations based on the available evidence.

The Medication Pathway and the Focus Area Definition

The pharmacist is essential in the verification of the medication prescription orders

and dispensing of medication, one of the greatest aspects of the medication pathways.

Medication dispensing means counting, labeling, and packaging medication for the client as

per the prescription orders. The main reasons for medication errors during dispensing include

illegible handwriting, interruptions such as phone calls from nurses/other healthcare team

members, failure to communicate medication orders, and drug confusion over similar
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packaging, etc. (Tariq et al, 2023). Also, the patients suffer from the physical and

psychological stresses associated with medical errors which results in unsatisfied patients and

their decreased trust in the healthcare system. Medical error has become a main problem

whereby around seven to nine thousand people die from medication errors. The total cost of

treating patients with medical-related errors exceeds forty billion US dollars (Tariq et al,

2023)

Analysis of the Area of Focus

Some reports highlight that pharmacists usually confirm the medicine prescriptions,

thus playing a part in the medication errors. Pharmacists also play a part in improving

medication adherence, offering medical counseling, and intervening to review the content of

prescriptions, thus reducing the MRCI score (Suzuki et al., 2022). As a pharmacist is

involved in the medication pathway from the beginning, it’s a better idea to implement

measures to mitigate medication errors at this level, so that the pathway can proceed

smoothly and efficiently later.

Pharmacists are responsible for medication errors as they are the ones dispensing the

medication after checking and verifying the physician’s orders and the data available about

the client. There are two types of errors pharmacists make judgmental or mechanical errors –

failure to detect drug interactions or counsel patients, inappropriate monitoring, etc. falls

under judgmental errors whereas mechanical errors are made during dispensing and preparing

medication such as dispensing the incorrect dose, quantity, or strength, giving improper

directions, etc. (Tariq et al, 2023). There are various factors responsible for medication errors

by pharmacists such as illegible handwriting, workload, similar drug names, interruptions,

lack of support staff, etc. In this paper, I will be focusing on unreadable handwriting and

doubtful prescription orders.

A study that was conducted showed that inclusion criteria were met by fifteen studies,

all of which were done in just four nations. Investigations of dispensing problems mostly

employed incident reports and direct observation. Depending on the dispensing mechanism,

research methodology, and categorization of dispensing fault types, dispensing error rates

vary between nations (0.015%-33.5%). The most commonly reported dispensing errors were

dispensing the incorrect medication, the incorrect drug strength, and the incorrect dosage

form (Aldhwaihi et al., 2016).

Recommendations

The analysis highlights that pharmacists play an essential role in reducing medical

errors. However, they still face the problems or challenges contributing to medication errors,

making the recommendations necessary to improve the patient's well-being. As discussed,

work interruptions and distractions are significant contributors to dispensing errors in hospital

pharmacies, along with illegible handwriting of physicians, doubt/confusion about an order,

high workloads, low staffing levels, mix-up of look-alike/sound-alike drugs, lack of

experience, and urgent deadlines/hurrying of tasks (Jaam et al, 2021). To alleviate the

medication errors due to the difficult-to-read medication orders and if the pharmacist is

doubtful about the medication prescription, there should be a provision to have the ward-

based pharmacist accompany the physician during unit rounds who can clarify unclear

medication orders and can provide real-time advice to the physician rather than suggesting

changes after prescribing has occurred (Jaam et al, 2021).

Illegible handwriting has plagued pharmacists for decades, often pharmacist is not

able to read the order and makes their best guess (Tariq et al, 2023). In case the drug is

required in an emergency, and the pharmacist cannot reach the physician to talk about the

medication order, the guess made by the pharmacist can be detrimental. This will save time
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also there is no need for the pharmacist to confirm the medication prescription in case of

doubt. This approach will be more successful with the pharmacist-led medication

reconciliation and the pharmacists can accompany the physicians during their rounds and

have detailed data about the client’s present and past medication lists, allergies, etc. It may

seem that this recommendation is putting some extra work for a pharmacist, but it also saves

time for the pharmacist as it removes any need to call a physician in case of an unclear order

as the pharmacist will clear doubts there and then. Moreover, the pharmacist can give any

specific recommendations related to medication to the client during the round and he doesn’t

need to visit the client again. This recommendation is also cost-effective as there is no need to

hire additional health professionals or to implicate any technological advancements. Apart

from this, if a physician makes any error, the pharmacist can keep a record and can later

utilize it for pharmacist-led educational interventions to alleviate the common errors made by

the physician.

Conclusion

Medication error is a common problem affecting patient safety, thus making the

pharmacist's role important in dispensing a critical medication path. The pharmacist can

contribute greatly to medication error by administering the correct drug at the wrong time,

receiving the wrong medication, encountering errors in the drug preparations, etc. The high

population is suffering from medication errors with a greater implication on the financial

aspect, thus making prescription and dispensing a paramount consideration in the medication

pathway. Most studies have proven the pharmacy's role to be essential in reducing medication

errors. The recommendation for a ward-based pharmacist assisting physicians during rounds

will reduce errors, be cost-effective, and make the dispensing and preparation of medication

an efficient process. This approach in the pharmacy department can improve workflow

efficiency while promoting safety, efficiency, and accuracy in various pharmacy settings.
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Thus, recommending ward-based pharmacists can reduce medical-related errors at medicine

dispensing can thus the medical-related errors significantly.

References

Aldhwaihi, K., Umaru, N., Pezzolesi, C., & Schifano, F. (2016). A systematic review of the

nature of dispensing errors in hospital pharmacies. Integrated Pharmacy Research

and Practice, https://doi.org/10.2147/iprp.s95733

Al-Worafi, Y. M. (2023). Medication errors case studies: Dispensing and administration

errors. Clinical Case Studies on Medication Safety, 133-

150. https://doi.org/10.1016/b978-0-323-98802-5.00007-8

Jaam, M., Naseralallah, L. M., Hussain, T. A., & Pawluk, S. A. (2021). Pharmacist-led

educational interventions provided to healthcare providers to reduce medication

errors: A systematic review and meta-analysis. PLOS ONE, 16(6),

e0253588. https://doi.org/10.1371/journal.pone.0253588

Kojima, T., Kinoshita, N., Kitamura, H., Tanaka, K., Tokunaga, A., Nakagawa, S., Abe, T., &

Nakajima, K. (2023). Effect of improvement measures in reducing interruptions in a

Japanese hospital pharmacy using a synthetic approach based on resilience

engineering and systems thinking. BMC Health Services

Research, 23(1). https://doi.org/10.1186/s12913-023-09346-2

Suzuki, R., Uchiya, T., Sakai, T., Takahashi, M., & Ohtsu, F. (2022). Pharmacist’s

interventions in factors contributing to medication errors reduces medication errors in

self-management of patients in the rehabilitation ward. Journal of Pharmaceutical

Health Care and Sciences, 8(1). https://doi.org/10.1186/s40780-022-00268-5