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Annotated Bibliography: Best Practices for Addressing Medication Errors

Create a 3-5 page annotated bibliography and summary based on your research related to best practices addressing a current health care problem or issue.
selected one of the problems/issues.
• Medication Errors
o Description: A medication error is a preventable adverse effect of a patient
taking the wrong medication or dosage, whether or not it is evident or harmful to
the patient. Medication errors can be a source of serious patient harm, including
death.
o Interventions: Electronic prescribing, pharmacist reviews, patient education.
o Keywords: Adverse drug events, medication reconciliation, patient safety,
medication administration, medication errors, medication safety.

Sample Answer

 

Annotated Bibliography: Best Practices for Addressing Medication Errors

Flynn, E. A., Barker, K. N., Carnahan, B. J. (2003). National observational study of prescription dispensing accuracy and safety in 50 pharmacies. Journal of the American Pharmaceutical Association, 43(2), 191-200.

This study examines the accuracy and safety of prescription dispensing in 50 pharmacies across the United States. The researchers found that medication errors occurred in 9.7% of prescriptions dispensed, with wrong drug and wrong dosage being the most common errors. The study highlights the need for interventions to improve medication safety, such as electronic prescribing systems and pharmacist reviews.

Kohn, L. T., Corrigan, J. M., Donaldson, M. S. (Eds.). (2000). To Err Is Human: Building a Safer Health System. National Academies Press.

This influential report from the Institute of Medicine (IOM) sheds light on the prevalence and impact of medical errors, including medication errors, in the healthcare system. It emphasizes the need for a systems-based approach to reduce errors and improve patient safety. The report provides recommendations for interventions, including electronic prescribing systems and medication reconciliation processes.

Leape, L. L., Bates, D. W., Cullen, D. J., et al. (1995). Systems analysis of adverse drug events: ADE Prevention Study Group. JAMA: The Journal of the American Medical Association, 274(1), 35-43.

This study investigates the causes and consequences of adverse drug events (ADEs) in hospitals. The researchers found that preventable ADEs were mainly due to errors in drug administration and monitoring. The study highlights the importance of system-level interventions, such as computerized physician order entry systems and pharmacist involvement, in reducing medication errors and improving patient safety.

Phansalkar, S., Edworthy, J., Hellier, E., et al. (2010). A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems. Journal of the American Medical Informatics Association, 17(5), 493-501.

This article focuses on the role of human factors in designing medication safety alerts within clinical information systems. It discusses the challenges of alert fatigue and provides recommendations for effective alert design to prevent medication errors. The authors emphasize the importance of tailoring alerts to specific patient populations and providing actionable information to healthcare providers.

Sweidan, M., Reeve, J., & Brien, J. (2011). Medication safety in acute care in Australia: Where are we now? Part 2: A review of strategies and activities for improving medication safety 2002-2008. Australian Journal of Pharmacy, 92(1095), 57-64.

This review article provides an overview of strategies and activities implemented in Australia between 2002 and 2008 to improve medication safety in acute care settings. It discusses the impact of various interventions, such as medication reconciliation processes, electronic prescribing systems, and educational initiatives targeting healthcare professionals. The article highlights the need for a multifaceted approach to address medication errors effectively.

Summary

Medication errors pose a significant risk to patient safety and can result in serious harm or even death. To address this issue, several best practices have been identified:

Electronic prescribing systems: Implementing electronic prescribing systems can help reduce medication errors by eliminating handwritten prescriptions and providing decision support tools for healthcare providers.

Pharmacist reviews: Involving pharmacists in the medication review process can identify potential errors or interactions, ensuring that patients receive appropriate medications at the correct dosages.

Patient education: Educating patients about their medications, including proper administration techniques and potential side effects, can empower them to be active participants in their own care and help prevent errors.

These interventions align with keywords such as adverse drug events, medication reconciliation, patient safety, medication administration, medication errors, and medication safety.

Research studies and reports have highlighted the need for a systems-based approach to address medication errors comprehensively. This includes implementing electronic prescribing systems, involving pharmacists in the medication review process, and providing patient education. Additionally, attention should be given to human factors principles when designing medication safety alerts within clinical information systems to avoid alert fatigue and enhance effectiveness.

By implementing these best practices and taking a proactive approach to medication safety, healthcare organizations can reduce medication errors and improve patient outcomes while promoting a culture of patient safety throughout the healthcare system.

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