The Problem Of Prevalence In Medication Errors

Approximately, a rate of 30 Adverse Drug Events (ADEs) occurs in every 100 admissions in New Zealand. The most common adverse drug events from medication errors, found were hypotension, bleeding, constipation, delirium/confusion and nausea/vomiting. These adverse effects also contributed to the patient’s length of stay, additional resources and therefore additional costs for the hospitals and DHBs. Examples of key causes that affected the prevalence of medication errors were found in medical inter-professionals, this included a lack of training in medication, knowledge and experience, insufficient awareness of the patient and the risks, exhausted and overloaded healthcare professionals and issues as poor communication between the multi-disciplinary team and the patient themselves. The most common error types found were to be wrong dose (25%), wrong medicine (22%), wrong strength (16%) and wrong patient (11%) and these occurred primally when the prescribing and administering of medications took place.

“Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”. Reason (1990) argues that errors are consequences of a proper activity not progressing as expected, hence the action being an error of the delivery or that the initial planned procedure not being precise therefore it being an error of planning. Reason, (2000), describes that there are two approaches to human error, the person approach and the system approach. The person approach aims attention on the errors and unsafe practice of people, accusing them of forgetfulness, negligence or ethical unprofessional practice. This results is shaming, disciplinary measures, blaming and so on, thus resulting in a sense of fear among healthcare professionals.

Reason (2000) mentions how every person is responsible for their own actions, choosing weather to work with safe or unsafe practice, however as a health professional you have a great responsibility to choose to practice safely, especially with medication error. Eliminating the healthcare professional for the sake of a mistake not being repeated again, is the primary idea of the personal approach in Reason’s (2000) concept. Reason’s (2000), human error system approach is a concept that suggests errors are prone to happen, even within the finest healthcare organisations. It takes into consideration the circumstances and the environment people work within and focuses more on the ‘why’ the error has happened rather than the ‘who’ is blamed for the error. Reason (2000) views error as the consequences of systemic factors in the workplace environment that gave way to the errors occurring in the first place. To avoid these errors the systems approach focuses more on the workplace as a whole, the multidisciplinary teams, their communication, team work and improving evidence-based practice for future preventative strategies within the organisation for medication errors. Reason (2000) developed the Swiss-Cheese model of organisation accidents to demonstrate the occurrence of organisational system failures and errors, such as medication administration errors. The slices of cheese represent the levels of defence an organisation has set and the holes in the cheese represent the latent conditions and active failures that occur. Active failures is a term that describes errors that occur through unsafe practice of an individual that is in direct contact with the patient, for example the non-adherence to safe practice guidelines such as the 5R’s of drug administration.

Latent conditions in error are known as the higher level decisions and systems put into place by the organisation itself. These can generate into error prone conditions such as understaffing, patient overload, time pressure and fatigue, lasting for a long time, creating a higher risk of error occurring. Once both the active failures and the latent conditions merge and the holes are aligned an error occurs.