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1 MEDICATION ERRORS IN HEALTHCARE Student’s Name Institutional Affiliation Course Date

2 Medication Errors in Healthcare Introduction Medication errors stand as a basic test in the healthcare domain, exerting profound effects on patient safety and the general quality of healthcare provision. The consequences of such errors, spanning from administration mishaps to breakdowns in communication, present substantial risks to patients, manifesting in adverse reactions, hospitalizations, and, in outrageous cases, fatalities. This paper explores the multifaceted dimensions of medication errors, emphasizing their expansive ramifications. Patients endow healthcare suppliers with the assumption of receiving accurate medications at precise doses. Nevertheless, errors in prescription administration upset the quality of care, possibly resulting in sub-optimal treatments that compromise patient well-being. The paper unfurls to explore the interconnected factors influencing medication errors, encompassing human considerations, patient security, healthcare quality, and the influence of clients and patients. It reaches out to examine national and state- level concerns, spotlighting initiatives in New York while proposing methodologies like medication reconciliation, technology integration, barcoding, instruction, and training, close by enhanced communication among healthcare professionals, as pivotal strategies for error prevention. This paper advocates for a collaborative, comprehensive approach across local, national, and state levels to mitigate medication errors, enhance patient safety, and fortify the healthcare system. Patient Security Medication errors may subject patients to incidences of harm, such as a severe response to drugs, desire for hospitalization, and even cases linked to death (Rodziewicz et al., 2023). Due to

3 the medication errors, Fox &Landon (2020) noted that the patients may end up receiving undesirable medication or incorrect dosage and, as a result, leading to severe reactions towards drugs. In this case, the reaction might entail side effects, allergic responses, or unanticipated relationships with related medications that the patient has been put on so far. Carver et al. (2023) also added that medication errors may call for the patient's admission to the hospital. For instance, when a patient, through mistake, is administered excess drugs, Hanson & Haddad (2022) cautioned that such a patient may end up developing symptoms that call for emergency attention and even hospitalization. Errors in medicine directly undermine attempts to offer safe care to patients (Rodziewicz et al., 2023). It is an obligation for healthcare workers to advocate for the safety of patients, for it is one of the healthcare industry's most important tenets. The Quality of Healthcare The quality of therapy delivered is directly tied to the effectiveness of healthcare (Rodziewicz et al., 2023). According to Menon et al. (2020), errors during the patient's medication will distort the quality of care. When the patient is provided with an ineffective substance or dosage that is incorrect regarding the prescription, it might lead to ineffective treatment (Rodziewicz et al., 2023). Medication is often used for addressing the unique medical status of a patient, much as the wrong medication may result in the patient never getting the therapeutic advantages that might have been the objective of the process. Consequently, the illness that the patient is suffering from may prolong, longer rehabilitation, or the condition worsening. Leape (2021) also noted that medication errors might lead to non-pleasing responses or consequences that demand patients to stay in the hospital longer. More medication measures and closer evaluation may be needed to reduce the detrimental effects or drug mistakes on the patient.

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4 As Kapaki (2022) pointed out, staying in a hospital not only leads to the overall expenses in medical care but also may negatively affect the overall quality, including the patient's life experience. Likewise, medication overdosing may result in a hazardous drug response, which may cause harm to the body. In this regard, Bell et al. (2020) identified that the patients may end up experiencing pleasing effects, allergic responses, and related health concerns that can be avoided by following effective medication administration. Thus, physical injuries do not just lead to a reduction in the care quality but also to an increment in suffering among the patients. Incorrect medication doses can increase medical treatment costs (Ofri, 2020). Extended hospital stays, the need for further treatments, and the need to address complications caused by pharmaceutical errors are all factors that contribute to increased healthcare expenses. Patients and healthcare systems alike may find it difficult to cover these costs. These errors not only cause damage, but they also have the potential to result in unfavorable outcomes, extended hospital stays, and increased overall healthcare costs. Human Considerations Medication administration is a sophisticated process requiring the participation of many medical experts, diverse equipment, and the patient. Human variables such as communication, workflow, and cognitive stress, among others, are frequently responsible for medication errors. Indeed, effective communication within the healthcare sector is critical to ensure that healthcare practitioners share the right and updated information (Weiner & Schwartz, 2023). Meanwhile, prescription errors may occur after the breakage of communication, especially when the professionals are never communicating clearly with each other, never conducting verification of the instructions governing the prescriptions, or fail to confirm the identity. For instance, in case

5 of misunderstanding regarding the patient's medication, either via writing or verbal, the patient might be accorded an undesired dosage or prescription. Medication administration at healthcare facilities is often reasonably complicated, comprising several phases, changes in duty, and checks at various times. Pharmaceutical errors are possible when these procedures are not well-structured, coordinated, or standardized. For example, if the workflow is fast or chaotic, this can lead to errors in prescription administration or inaccurate medicine labeling. Alghamdi et al. (2019) added that those in the healthcare industry commonly work in high-pressure environments that make tremendous demands on their cognitive capacities. The cognitive load is the mental activity required to grasp and recall information. When healthcare workers are under a lot of cognitive pressure, they may be more prone to making mistakes, including blunders in prescription administration. Carver et al. (2023) asserted that this could happen if they juggle many patients, medications, or a complicated treatment plan. First, it is critical to grasp these factors to improve patient safety. Client and Patient Influence Medication mistakes can have many consequences for patients and customers, including the following. Other consequences of medication errors are physical harm, allergic reactions, undesirable pharmaceutical effects, and, in extreme situations, fatalities (Fox &Landon, 2020). Medication errors can directly injure the patient or consumer, causing them to experience physical symptoms. In this regard, this can include allergic reactions, severe pharmacological effects, or even fatalities in the most extreme cases. Individuals are in danger of immediate and potentially lethal consequences if they obtain the incorrect medication or an incorrect dose of that medication.

6 Long periods of recuperation as a result of ineffective treatment or inadequate management. Medication errors might lengthen the time it takes to recover. In case a patient is placed on the wrong drugs or ineffective treatment, Carver et al. (2023) noted that their present health issues may worsen or register improvements as expected. Eventually, this might lead to prolonged hospital stays and delays in the patient returning to normal health. Meanwhile, according to Hanson & Haddad (2022), emotional forms of distress and the missing trust are expected within healthcare facilities. As a result of pharmaceutical errors, patients and clients may feel emotional distress. Learning that a healthcare practitioner made a mistake in their treatment can be a terrible experience for a patient. Carver et al. (2023) added that it may also induce anxiety and a lack of trust in the healthcare system. Patients may begin to have worries about the doctors' level of skill and safety, resulting in emotional suffering that may persist even after the error has been remedied. An increase in overall healthcare costs is due to the need for additional treatments and longer hospital stays. Medication errors have the potential to raise healthcare costs. In scenarios where the patient has a wound following the drug error, Menon et al. (2020) said that the patient may require more medications or a prolonged stay within the hospital to address repercussions linked to the injury. Leape (2021) added that the additional medications may contribute to a price increase that may never be financially easy for people, including the healthcare system. National and State Concerns (in the State of New York) . Medication mistakes are a major concern nationally and in New York, which can substantially impact patient safety. Thus, there exist certain concerns and initiatives linked to the cases of drug mishaps within New York State. One of them is the patient safety, which has been a major concern at the state and national levels. As cited by Bell et al. (2020), medication errors

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7 may lead to hazardous drug response, hospital admissions, and instances of death. Thus, in New York, healthcare facilities must report and analyze prescription mistakes. According to Ofri (2020), this helps in knowing the patterns and the major causes that may be used in developing policies to prevent medication errors. The adoption of electronic health records (EHRs) and computerized physician order entry (CPOE) systems is encouraged to prevent pharmaceutical errors. New York urges healthcare facilities to implement this technology to improve medication safety (Leape, 2021)). Likewise, many New York healthcare organizations have created medication safety committees. Thus, these committees recognize and reduce drug errors inside the organization. Besides the same, Kapaki (2022) stated that healthcare personnel are provided education and training to improve their drug management abilities and awareness of medication safety principles. As a result, this training aids in the prevention of errors. New York adheres to national medication administration standards and guidelines to promote safe drug practices, including those established by organizations such as The Joint Commission. Likewise, regulatory authorities, such as the New York State Department of Health (NYSDOH), monitor healthcare institutions and enforce medication safety standards. Inspections and investigations are carried out to ensure compliance (Menon et al., 2020). Similarly, New York has systems for reporting and recording medication problems. Hence, this information is used to measure the prevalence and impact of errors, allowing for targeted interventions. Not forgetting, New York healthcare facilities are encouraged to participate in quality improvement programs to eliminate prescription errors. These programs frequently include data collecting and analysis to find areas for improvement. Local Level Concerns (in New York City)

8 Medication errors are vital issues within New York City, and several hospitals, including other healthcare institutions, have unique laws, including programs for handling the issue and initiatives for addressing the issue (Weiner & Schwartz, 2023). Safety checks, technological introduction, and employee training programs may constitute part of them. Local-based healthcare institutions, including hospitals, may implement added safety-based standards for meeting their patients' unique needs, including intricacies linked to the healthcare delivery system for the city (Carver et al., 2023). Because their major goal is to reduce prescription errors, these protocols usually incorporate double checks, verification procedures, and other error avoidance approaches. National And State-Level Benchmarks National objectives, such as those listed in "To Err is Human," aim to reduce drug mistakes and enhance patient safety. Alghamdi et al. (2019) noted that the standards are present within the US. State-oriented standards might not be the same as each other. However, on many occasions after that, ensuring consistency with the national set goals and suggestions after reducing the incidence of drug errors. National and state-level benchmarks are critical for improving pharmaceutical safety and patient outcomes (Carver et al., 2023). For instance, they create goals, guide policy development, and enable efforts to achieve continuous improvement in healthcare. By aligning themselves with national standards and adjusting those recommendations to local settings, healthcare institutions can work toward reducing prescription errors and enhancing patient safety at both the national and state levels. Carver et al. (2023) said this is possible at national and state levels. Methodology and Problem Solving

9 Medical mistake research has focused on various aspects of the problem, including its fundamental roots, preventative efforts, and best practices. Consequently, there are factors contributing to pharmaceutical errors and delves deeper into the underlying causes of medication errors. According to Leape (2021), this encompasses human factors, system issues, communication failures, and workflow challenges. To develop effective preventative measures, it is vital first to identify the underlying reasons. Studies about pharmaceutical errors often have led to detailed knowledge about the issue, ranging from the essential origins to the prevention techniques, including the desired practices invented so far (Hanson & Haddad, 2022). Professionals in healthcare and researchers are including new content in the body of ideas to improve the safety of the patient and minimize the cases of drug errors. The renowned tactics are an evaluation of the existing causes of the issue, iterative improvements towards the desirable process, and multifaceted teamwork from the side of healthcare professionals. Past studies concerning the subject, especially from Menon et al. (2020), have suggested various approaches, including medication reconciliation, technology integration, barcoding, communication among professionals, instruction, and training. Reconciliation of Medication Implementing complete medication reconciliation practices during care transitions is the process of dodging inadvertent inconsistencies through a complete review of the medication given to patients during admission, transfer or discharge (AHRQ, 2019). During the medication reconciliation process, Leape (2021) said that a whole and precise list comprising every patient who has been prescribed drugs is generated and then compared with the prescription given by the doctor, plus the clinical decisions arrived about the outcomes after conducting the comparison. The technique in this regard is vital during the care transitions, especially when the patient has

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10 been hospitalized or released from the facility (AHRQ, 2019). The reconciliation helps ensure the patient continues receiving the essential medication (Kapaki, 2022). At the same time, it assists in knowing about the anomalies and cases of discrepancies, including the resolution of the issues, which in turn enables the avoidance of medication errors. Technology Integration The use of health information technology, such as computerized physician order entry (CPOE) systems, to reduce the amount of prescription errors is referred to as technology integration. Health information technology, such as computerized physician order entry (CPOE) systems, is crucial to reducing prescription delivery errors. Bell et al. (2020) said these technologies enable medical practitioners to enter and manage medicine orders electronically. At the same time, they have built-in safety checks, including allergy alerts and dose range checks, to help spot potential problems before they are provided to the patient. Furthermore, electronic health records (EHRs) increase drug safety by storing patients' medication histories in a single, structured, easy-to-access location. Barcoding The use of barcode technology to match medications with patient IDs reduces errors during administration (Mulac et al., 2021). Since barcode technology is used to connect pharmaceuticals with the identities of specific patients, it is an important tool for eliminating errors in drug delivery (Ofri, 2020). Medical practitioners can check that the correct medication is being administered to the correct patient by scanning barcodes on patient bracelets and drug labels (Mulac et al., 2021). This technique adds extra security, which is very useful in high-risk areas.

11 Adaptation of this technology also improves the quality of the provided care and leads to user satisfaction. Instruction & Training Providing ongoing training and teaching to medical professionals on the best methods for administering and handling drugs safely is essential. To limit the risk of drug mistakes, healthcare staff must participate in continual education and training (Weiner & Schwartz, 2023). Training programs must emphasize the best procedures for drug administration, safe medication handling, and the importance of double-checking pharmaceutical orders. Continuous education allows healthcare workers to stay current on the latest safety laws and best practices. Communication Among Professionals Increasing communication and coordination across diverse healthcare teams to increase patient safety is important. To lower the risk of drug errors and increase patient safety, healthcare teams must effectively communicate with one another and collaborate (Alghamdi et al. 2019). Multidisciplinary teams must work together to ensure that medication orders are followed accurately, to resolve any conflicts that may develop, and to discuss any changes in a patient's condition. Miscommunications can be prevented, and medication safety can be enhanced by establishing open and transparent communication lines. Conclusion To sum up, this paper has featured the unavoidable issue of medication errors in healthcare, underlining their profound effect on patient safety and the general quality of healthcare delivery. Medication errors, going from administration mistakes to communication breakdowns, present huge risks to patients, prompting adverse reactions, hospitalizations, and

12 even fatalities. The conversation has highlighted the significance of tending to medication errors through a multifaceted approach, including factors like human considerations, patient security, the quality of healthcare, and the impact on clients and patients. The paper has examined the national and state-level concerns, giving knowledge into initiatives attempted in New York, and has investigated different methodologies for forestalling and moderating medication errors, including medication reconciliation, technology integration, barcoding, instruction, and training, as well as further developing communication among healthcare professionals. Also, the paper has demonstrated that moderating medication errors demands collaborative efforts at local, national, and state levels. The incorporation of technology, comprehensive training, and effective communication strategies is basic to improve patient safety and raise the quality of healthcare. By carrying out proactive measures and sticking to national and state-level benchmarks, healthcare institutions can endeavor to limit medication errors, prompting improved patient outcomes and a more robust healthcare system. This comprehensive approach is urgent for tending to the complexities encompassing medication errors and fostering a healthcare environment that prioritizes patient well-being and safety.

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13 References AHRQ. (2019, September 7). Medication Reconciliation | PSNet . Ahrq.gov. https://psnet.ahrq.gov/primer/medication-reconciliation Alghamdi, A. A., Keers, R. N., Sutherland, A., & Ashcroft, D. M. (2019). Prevalence and nature of medication errors and preventable adverse drug events in pediatric and neonatal intensive care settings: a systematic review. Drug safety , 42 , 1423-1436. DOI: 10.1007/s40264-019-00856-9 Bell, S. K., Delbanco, T., Elmore, J. G., Fitzgerald, P. S., Fossa, A., Harcourt, K., ... & DesRoches, C. M. (2020). Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA network open , 3 (6), e205867- e205867. DOI: 10.1001/jamanetworkopen.2020.5867 Carver, N., Gupta, V., & Hipskind, J. E. (2023). Medical Errors. In StatPearls [Internet] . StatPearls Publishing. DOI: 10.1001/jamanetworkopen.2020.28780 Fox, R. M., Landon, C. (2020). Avoiding Medical Errors: One Hundred Rules to Help You Survive Mistakes by Doctors and Hospitals. United States: Rowman & Littlefield Publishers.

14 Hanson, A., & Haddad, L. M. (2022). Nursing rights of medication administration. In StatPearls [Internet] . StatPearls Publishing. Kapaki, V. (2022). The Anatomy of Medication Errors. (n.p.): (n.p.). Leape, L. L. (2021). Making Healthcare Safe: The Story of the Patient Safety Movement. Germany: Springer International Publishing. Menon, N. K., Shanafelt, T. D., Sinsky, C. A., Linzer, M., Carlasare, L., Brady, K. J., ... & Trockel, M. T. (2020). Association of physician burnout with suicidal ideation and medical errors. JAMA network open , 3 (12), e2028780-e2028780. Mulac, A., Mathiesen, L., Taxis, K., & Granås, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety , 30 (12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 Ofri, D. (2020). When We Do Harm: A Doctor Confronts Medical Error. United States: Beacon Press. Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2023, May 2). Medical error reduction and prevention . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/ Weiner, S. J., & Schwartz, A. (2023). Listening for what matters: avoiding contextual errors in health care . Oxford University Press.

lit review med errors.edited

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