Question

what uncontrollable external factors influence medication error in a skill health facility ?

How did equipement performance affect medication error?

find the root couse annalysis of the above.

Answer 1

Errors arise when an action is intended but not performed; errors that arise from poor planning or inadequate knowledge are characterized as mistakes; those that arise from imperfect execution of well-formulated plans are called slips when an erroneous act is committed and lapses when a correct act is omitted. Some tasks are intrinsically prone to error. Examples are tasks that are unfamiliar to the operator or performed under pressure. Tasks that require the calculation of a dosage or dilution are especially susceptible to error. The tasks of prescribing, preparation, and administration of medicines are complex, and are carried out within a complex system; errors can occur at each of many steps and the error rate for the overall process is therefore high. The error rate increases when health-care professionals are inexperienced, inattentive, rushed, distracted, fatigued, or depressed; orthopaedic surgeons and nurses may be more likely than other health-care professionals to make medication errors. Medication error rates in hospital are higher in paediatric departments and intensive care units than elsewhere. Rates of medication errors may be higher in very young or very old patients. Intravenous antibiotics are the drugs most commonly involved in medication errors in hospital; antiplatelet agents, diuretics, and non-steroidal anti-inflammatory drugs are most likely to account for ‘preventable admissions’. Computers effectively reduce the rates of easily counted errors. It is not clear whether they can save lives lost through rare but dangerous errors in the medication process.

A medication error is taken to be ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. The treatment process includes the prescribing, transcribing, manufacturing or compounding, dispensing, and administration of a drug, and monitoring therapy. Each of these separate activities has many components. For example, a single prescription on our hospital drugs chart requires the prescriber to include 21 separate pieces of information, such as the patient's date of birth and the time of administration of the prescribed drug. Each entails an action with the potential for error.

In the recent years, a variety of factors such as raising trend of drug production has increased the risk of medication errors. There are many factors associated with medication errors. Errors related to medication are more or less limited to errors that occur when the patient receive the medication or is scheduled to receive it. These errors are mainly related to nursing care including error in medication administration and omission. Medical errors occur when one or more of the five principles of medication are violated including choosing the right patient, right dosage, right medication, right time and right method of administration. The omission errors occur when the patient does not receive the medication at all. In most of the cases, the errors were giving the wrong dose of the drug omission in medication.

Nurses make up the largest group of health workers. Hence, quality of health care depends to a great extent to nurses. Nurses are the major responsible persons for giving medication. Medicine administrations consume more than 40% of the nurses’ time. Medication errors may occur in all types of prescription and occur mainly in the preparation, delivery, and administration of medication. The human factor is the main cause of medication errors. Nurse’s knowledge and experience is a signifi cant factor related to nursing, which have a signifi cant impact on the quality of nursing care, including drug prescription. One of the reasons behind it might be a defi ciency of nurses’ knowledge on drugs and their need for training. Primary and natural result of medication errors, which is the most common events in a nursing profession could increase the length of hospital stay leading to increased hospital costs and in some cases may initiate severe injury or even death.

Nurses who must have more than one job have lower levels of attention and concentration, and experience more stress, when performing their professional activities. Therefore, these professionals are prone to make mistakes, due to their high levels of physical and emotional exhaustion, which can lead to a lack of attention and reduce the quality of their professional care Factors such as inadequate communication between team members, environmental performance, increased workload, low precision, neglect, low work experience, less education are all effective in committing nursing errors. Medication errors are no different in their genesis from other human errors: some result from poor knowledge or defective plans, and some from the unavoidable slips and lapses that are inevitable dangers in routine acts. Checking should intercept errors, but what little evidence is available suggests that routine checking is sometimes little more than ritual. While computers can effectively reduce the rates of easily counted errors, there is much less evidence that they can save lives lost through rare but dangerous errors in the medication process. The use of computerized electronic prescription systems is one possible solution to this problem, as when the information is entered into the system, it can be correctly and easily understood. In addition, some systems can assist the physician in selecting the appropriate drug and describe the possible drug interactions or adverse effects.