Healthcare professionals, especially nurses, must adhere to safety guidelines by observing various “rights,” including the right patient, doses, time, routes, and documentation during medication administration practices. Medical administrators must incorporate evidence-based practice and best strategies to safeguard patient safety and avert errors. Therefore, this paper describes a scenario of medication administration mistakes while elaborating root causes, evidence-based strategies, and organizational resources for preventing MEAs.
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Analysis of the Root Cause
Medication administration errors are preventable acts that result in improper medication use in the treatment process, leading to multiple safety concerns such as adverse reactions, disability, and death (Tsegaye et al., 2020). In this sense, healthcare professionals responsible for administering regimens to patients fail to uphold the “medication rights” such as correct dosage, administration routes, documentation, and frequency due to the prevailing organizational, human, and technical factors. As a registered nurse operating in a skilled nursing facility (SNFs) in the cardiovascular care department, I have witnessed numerous scenarios where caregivers commit near misses or actual errors that lead to adverse medical outcomes.
In one instance, a registered nurse (RNs) tasked to administer digoxin doses to a 50-year-old male patient with arrhythmia episodes decided to delegate medication administration practices to unlicensed assistant personnel (UAP). Often, our organization allows registered nurses to delegate responsibilities to UAPs after conducting competency assessments and knowledge enhancement programs such as training and educational interventions. Although the nurse had fulfilled such guidelines, the delegate committed an error by administering incorrect dosage at the right time.
After observing the patient’s reactions, the nurse assistant detected the mistake that suggested potential digoxin toxicity, including nausea, vomiting, and irregular heart rhythms. After identifying the error, the nurse assistant did not communicate early or alert the delegator about the incident. Fortunately, one on-floor nurse saved the patient from the impending safety threats by administering an antidote. From such a scenario, l learned about the root causes of medication administration errors and possible ways to prevent mistakes.
Many scholarly studies provide evidence about the root causes of medication administration errors consistent with the case study. For instance, Vaismoradi et al. (2020) contend that various institutional factors facilitate medication mistakes. These factors include organizational patient-safety culture and environment, nurses’ workloads, the effectiveness of interprofessional collaboration and communication, the presence of education and training programs for nurses, and the availability of institutional guidelines for medication administration.
In this sense, health organizations should provide opportunities that enable healthcare professionals to adhere to and comply with patient-safety principles. In our case study, timely incident reporting and effective communication between the nurse assistant and the delegator nurse would have prevented an error that almost claimed the patient’s life.
Other primary causes of medication administration mistakes are technical and human factors. In organizations where clinicians use computerized physician order entries (CPOEs) and automated medication administration technologies, incidences of technical glitches may compromise medication administration practices leading to errors of commission and omission. Although technical factors are often accidental and unanticipated, human factors are significant causes of medication errors.
Tsegaye et al. (2020) argue that medication administration mistakes occur due to various human-related issues, including the level of knowledge and training on medication administration practices, work experience, familiarity with organizational guidelines, ability to communicate and report near misses or actual sentinel events, and competencies to adhere to safety guidelines. Since a human is to error, it is essential for healthcare organizations to invest massively in implementing evidence-based and best practices for enhancing employee competencies and knowledge of safe
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