Medication errors investigation

Currently, many organizations take an ineffective approach to preventing medication errors. Investigations tend to focus on th e front end or active endot the error... 

A panel of experts brought together to investigate prescription drug errors in hospitals reports that medication errors harm 1.5 million people each year and increase medical care costs by 3.5 billion. 

Currently, many pharmacies have an ineffective approach to error reduction. Investigations that occur during the error reporting process tend to focus their attention on the front end or active end of the error such as the front-line practitioner (e.g., a technician preparing a prescription or a pharmacist dispensing the medication). Human nature tends to assign blame to these front-line practitioners involved in medication errors. It is easier and in our nature to blame individuals and resort to familiar solutions disciplinary action, individual remedial education, placing error information... 

Studies of medication errors, as we have seen, assess whether a dmg was prescribed and administered correctly there may or may not have been any actual or potential harm to the patient. Studies of adverse drug events, in contrast, focus on the harm, which may or may not have been caused by an error. For instance, if a patient suffers an allergic reaction which could not have been predicted then this is unfortunate, but not an error. If their medical record specifies the allergy and they are still given the drug, then it certainly can be classed as an error, although investigation may reveal a quite complex net of causes. 

Hofman, D.A. and Mark, B. (2006) An investigation between safety climate and medication errors and other nurse and patient outcomes. Personnel Psychology, 59, 847-869. 

Lim, R.H.M. 2008. A Systems Approach to Medication Safety in Care Homes Understanding the Medication System, Investigating Medication Errors and Identifying the Requirements of a Safe Medication System. PhD thesis, University of Surrey. 

Darren M. Ashcroft is a pharmacist and Professor of Pharmacoepidemiology at the University of Manchester, UK. He is the research theme lead for medication safety in the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre and has led work investigating incident reporting, medication error and safety culture in a range of healtheare settings. 

Uribe, C. L., et al.. Perceived Barriers to Medical-Error Reporting An Exploratory Investigation, Journal of Health Care Management, Vol. 47, No. 4, 2002, pp. 263-280. 

Barbara Mark and David A. Hofmann, "An Investigation of the Relationship Between Safety Climate and Medication Errors as Well as Other Nurse and Patient Outcomes," Personnel Psychology, 59 (2006) pp. 847-869. 

Blame is rarely an appropriate response to a medical error. Of course there are rare situations where blame is appropriate for example, criminal behavior, insubordination, or refusal to respond to feedback. But these behaviors are rare and seldom the cause of preventable adverse events. On the other hand, a culture of blame is an exceedingly common problem in healthcare and frequently contributes to adverse events by impeding detection, investigation, and remedy. Every effort should be made to eliminate blame from healthcare s culture. 

Research supports a systems approach to error prevention as well as investigation of errors [8-11]. This means that all aspects of the medication use process, including characteristics of the products themselves should be explored for ways to improve safety in use. 

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