Major root cause of medication administration errors

Analysis
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Root-Cause Analysis
Health centers are supposed to be where injured, and ailing people run for safety and medical attention. However, sometimes, people come out of these places with more complicated issues than the way they come. The major cause of these instances of complications happening in healthcare is medication errors. Medication administration errors have been reported to be a common error that nurses make to result in more complications for the patients in their care. Medication administration is guided by five Rs, which are the right patient, time, dose, medication, and the right route of administration. An error in medication administration happens when one or all of the guiding factors are breached. These five rights are incorporated into the nursing syllabus to ensure that all nurses have the standards for patient safety (Salami et al., 2019). However, medication administration is not one-person dependent. It is a complex system that is made up of different people at different parts of the process. The work of administering the medicine to the patient is the last part that happens to be the most studied of the whole process.
The Root-Cause of Medication Administration Errors
Medication administration errors have been studied for some time and from different perspectives to determine the root cause. Miscommunication is the major root cause of medication administration errors. Communication breakdown or wrong interpretation of communication has resulted in major problems administering medicine to the patients. Medical care is a complex system dependent on the other for its success. The breakdown of information from any part of the system may lead to a failure in the whole system. Medication administration happens to be the core part of the process where the nurse and the patient interact (Salami et al., 2019). Suppose a problem or a risk to the patients safety is not noted during the process. In that case, the nurse will administer the wrong medication and will eventually get the blame for problems with patient safety. The complex system involves drug purchase and dispensing personnel, storage, labeling, diagnosis, patient examination personnel, pharmacists, and nurses administering the drugs. Miscommunication can occur at any point of the chain.
Miscommunication happens in different forms in healthcare and from different channels. Communication happens between the nurse and other nurses, doctors, or other personnel in the system (Hammoudi et al., 2018). It also occurs between the nurse and the patient. Any channels above can be the source of miscommunication, leading to medication administration errors. For example, the nurse communicates with other nurses during a shift change and can give wrong information about medication records to the nurse coming to the next shift. It can also happen that the other nurse can have a wrong interpretation of the information given to them. The same problem applies to the communication between a nurse and doctors, pharmacists, or other personnel essential in medication administration. A communication breach can also happen between the nurse and the patient. The nurse can have the wrong guidance on the patients condition and transfer the same information to the patient. This communication often results in errors when the patient is in home-based care where they take care of themselves or their families. The patient can also be the source of wrong information to the nurse, especially when they operate on changing shifts. The patient might lie about their conditions, intending to get out of given medical care or drugs.
Miscommunication in healthcare happens in many forms from one department or person to another. Documentation and record-keeping are common ways that the patients history and progress are kept and communicated from one person to another (Hammoudi et al., 2018). Miscommunication can happen in the record by feeding wrong information or mixing up patients information. In healthcare systems where manual record-keeping is still used, mix-up of records is a major problem which is also a form of miscommunication. Electronic record-keeping is increasingly being implemented in many healthcare systems, yet many nurses do not have the know-how to use these machines (Risr et al., 2018). Drugs must always be labeled for the ease of access and avoidance of mix-ups of the drugs. A breach in communication also happens when the labels are not well put. Some drugs look very similar to others, which is often the cause of this mixt-up of information. The nurse may be given a drug from the store, yet it is the wrong one in a container labeled for the needed drug.
Every organization has an internal language that the member understands. This aspect is obtained from understanding organizational culture, which includes the language that the members of that culture are used to and understand. In healthcare systems, the members also develop these languages, which they use among themselves. As a result, the language may not be common and understandable for anyone who does not come from the culture. In such a setup, there is a high risk of miscommunication, especially if there is a new employee. New members may take some time before getting used to the language, sometimes confusing it with one of the previous cultures. Another major problem of miscommunication happens because of the handwriting of the people involved, from the person who makes the diagnosis and recommendation of the drugs and the nurses involved in record keeping. Bad handwriting makes people misread what is in the records and the drug recommendation.
Evidence-Based Strategies
Healthcare is an evolving profession that requires a constant check for updates. Medication administration is recorded to harm at least 1.5 million patients each year. The administration is recorded to have the most impact on the errors in the whole medication process. Medication errors do not only affect the patients who get injured in the process but also the facility. The institution is forced to use more resources to counter the problems caused by the errors in medication. For instance, a hospital may record a loss of at least $3.5 billion in a year without wages and all other financial expenses that may be incurred from the fault. The issue of patient safety has been acknowledged to be a the medical field. Many organizations like the Academy of Managed Care Pharmacy (AMCP) are involved in supporting programs that aim at reducing the risks of medication administration errors and other issues affecting patient safety (., 2018). Its framework for Quality of Drug Therapy promotes and insists on public safety, a continuous check of accuracy in the distribution and administration, reliability of the transfer of information about the diagnosis, prescription, and order, and a constant reviewing and updating of the hospitals operating system.
Improvement Plan
With the basic understanding that medication administration involves a complex process involving many people, medication administration error is no longer addressed by factors that target the nurse who administers the drug. The five rights of medication are no longer the only aspects monitored when examining medication errors. A plan to improve patient safety proposed the addition of four other rights as a strategy to involve other parties involved in the process of medication administration (Tariq et al., 2018). The four other rights are right documentation, reason/action, response, and form.
The Healthcare delivery system is a continuously evolving entity. Implementing technology in the system has been a major issue slowly taking shape. The system looks keenly into the operation design with a major focus on technology and clinical workflow. It is working to look for means of increasing accuracy and efficiency in drug administration through technology (Risr et al., 2018). The errors that occur in healthcare institutions that have implemented technology that administers these drugs are errors caused by human causes rather than the technology. These issues include inadequate training, convoluted process, distractors while operating the machines, and system misconfiguration. Implementation of new technology does not mean that medication administration errors have been reduced; there yet remain many other things to be done integrally with technology to help reduce the prevalence of the errors.
Other improvement plans that will help maximize patient safety include educating nurses and the patients. Many medication errors are reported to take place away from healthcare facilities. Patients should be involved in health education and awareness. They should be taught the appropriate use of medications prescribed to them. Nurses should be kept in check and constantly trained on new medicine and treatment methods. Proper education for patients and nurses is a program that will greatly help in error prevention. All the parties will be alert in safeguarding against medication administration errors (Tariq et al., 2018). Training the nurses and all the personnel involved in medication administration is linked to education. The training program includes keeping them up-to-date with the medical language and terms needed in the service and using new technology for medication administration. The working plan for the healthcare system is to install the latest technology to help reduce these errors and ensure that all people who use the technology are trained on how to operate them. They include bar coding machines, electronic prescription records, drug utilization reviews, and automated medication dispensing machines.
Conclusion
Medication administration errors are not intentional to make the perpetrators to be judged harshly. All people, including the patients, have a major role in preventing these medication errors. The nurses are at the lowest part of the chain of medication administration because of their direct involvement with the patients. Therefore, everyone involved in the chain of drug handling should be a part of ensuring that errors in medication administration are prevented. Everyone should be on the lookout for any risk factors that may amount to medication administration errors. The healthcare delivery system should be open to involving different parties and mechanisms to help identify error-prone factors in the medication process. These programs that aim to reduce errors are necessary for every healthcare delivery system.

References
Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them.Scandinavian Journal of Caring Sciences,32(3), 1038-1046.
Risr, B. W., Lisby, M., & Srensen, J. (2018). Complex automated medication systems reduce medication administration errors in a Danish acute medical unit.International Journal for Quality in Health Care,30(6), 457-465.
Salami, I., Subih, M., Darwish, R., Al-Jbarat, M., Saleh, Z., Maharmeh, M., … & Al-Amer, R. (2019). Medication administration errors: Perceptions of Jordanian nurses.Journal of Nursing Care Quality,34(2), E7-E12.
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/.