Analyze a Current Health Care Problem or Issue

Analyze a Current Health Care Problem or Issue

Analyze a Current Health Care Problem or Issue

Upon arrival to a healthcare facility the patient expects professional expert care. The
expectation is to receive competent care, free from any harm for their symptoms/illness.
Management of a patient with medication is the most common form of treatment, making
medication error the most common mistake. Medication errors can occur at any point of the
medication event timeline, including prescribing the medication, acquisition of the medication,
route, dosage, patient, and timing of the medication. Medication errors endanger patient safety,
causing a substantial monetary strain on healthcare systems through increasing healthcare costs.
“Worldwide, medication errors cause at least one death per day and cost an estimated $43 billion
annually”, injuring 1.3 million each year. (Right dose, right drug: WHO challenges hospitals to
cut med errors in half.2017) For this paper, a medication error is defined as an avoidable incident
that can result in harm or injury while the medication is in the control of the healthcare
professional or patient. Averting medication errors is fundamental to cultivating a safe healthcare
system. Only the medical and nursing professions produce graduates who are equipped to
administer injury free patient care. Because nurses are the last line of defense to prevent
medication errors, it is their duty to halt anything that decreases the quality of healthcare. This
paper addresses components that cause errors and the needed changes to reduce those errors.

Elements of the Problem/Issue

The causes of medication errors are varied and complex because medication
administration is one of the most routine yet highly complex activities of the nurse (Jember et al.,
2018). The number of causes amounted to over thirty, during the research for this paper, so for
the purpose of this paper, the list was trimmed to two system-related factors and two nurse-

ANALYZE A CURRENT HEALTH CARE PROBLEM OR ISSUE 3

related factors. Most medication errors can easily be rectified, prior to a serious consequence
occurring, with most errors caught by the nurse and the pharmacist.
The two system-related factors discussed here include the failure to adhere to the
authoritative policies/protocols provided by the institution and the shortage of staff on the unit.
Nurse-related factors discussed include nurse interruptions or distractions while administering
medications and inexperienced nurses.
Failing to adhere to the authoritative policies and protocols provided by the institution
through implementing shortcuts, skipping steps or omitting best practices contribute to
medication errors. The most common cause of medication error is a “flawed or absent patient
identification process.” (Oops, sorry, wrong patient! A patient verification process is needed
everywhere, not just at the bedside.)
Härkänen et al. (2018) explained that the shortage of staff in unit created by
overcrowded facilities, increased acuity of patients, and expanded demands placed on nurses all
contribute to medication error. Nurses have admitted that heavy workloads resulting in the
feeling of stressed is a factor in medication errors
Distractions/interruptions are frequent causes of medication errors. One study showed
nurses were “interrupted an average of 43 times in a ten-hour period” during the medication
administration process. (An urban medical system's exploratory study of medication errors -
ProQuest.) Other studies have shown the “17% of all medication administrations were
interrupted in some way.” (An urban medical system's exploratory study of medication errors -
ProQuest.) Numerous studies have shown that distractions and interruptions were one of the
major issues contributing to the nurse making the error. (The safe administration of medication:
Nursing behaviours beyond the five-rights.2019; Agyemang & While, 2010)