D221 – PA: Addressing Medication Errors in Healthcare Settings

Student Name

Western Governors University

D221 Organizational Systems and Healthcare Transformation

Prof. Name:

Date

A. Systems-Level Safety Concern in a Healthcare Setting Using SBAR Format

Situation (S)

Medication administration remains one of the most critical and frequent nursing tasks across healthcare environments. It presents a significant patient safety concern at the systems level because errors during medication delivery can affect multiple patients and lead to serious harm or death. These errors include administering the wrong medication, incorrect dosage, improper timing, or giving high-risk medications without necessary lab or vital sign assessments. Additionally, adverse drug reactions or allergic responses post-administration also pose substantial risks. Therefore, patient safety must be the highest priority, emphasizing nurses’ roles in infection control, interdisciplinary communication, and safe medication practices to prevent such errors.

Background (B)

Medication errors in healthcare settings are alarmingly common and costly. In the United States alone, 7,000 to 9,000 people die annually due to medication administration errors, while hundreds of thousands experience adverse reactions that may go unreported (Tariq et al., 2023). Errors can occur at any stage of the medication process, including prescribing, transcription, dispensing, and administration. Providers may make mistakes due to inadequate drug knowledge, illegible orders, or failure to check allergies. Nurses may err when selecting medications with similar names, incorrect dosages from dispensing units, or failing to scan barcodes for patient and medication verification. Implementing electronic barcode scanning systems significantly reduces these errors.

The Joint Commission has established patient safety standards applicable to this issue. For instance, ensuring the correct patient identity via two identifiers (e.g., name and date of birth) is mandatory before medication administration. For high-risk or pediatric medications, a second nurse’s verification is recommended (The Joint Commission, 2021). Additionally, the safe use of medicine involves verifying correct medication, dose, timing, route, and documentation. Labeling medications prepared in syringes or IV bags immediately and maintaining accurate IV line documentation are also crucial to prevent errors.

Assessment (A)

The consequences of medication errors on patients range from mild adverse effects to fatal outcomes. Such incidents can erode patient trust, potentially discouraging individuals from seeking necessary healthcare, worsening their health status. Nurses administering medications often face disciplinary actions, including license suspension or criminal charges, causing emotional distress and guilt. For healthcare organizations, medication errors result in financial burdens—costing billions annually—and negatively impact institutional reputation and patient safety records (Tariq et al., 2023).

Impact on Stakeholder	Description
Patient	Risk of harm, deterioration of condition, loss of trust in healthcare, and adverse drug reactions
Staff (Nurses)	Disciplinary actions, mental anguish, legal consequences
Organization	Financial costs, negative safety record, investigations, reduced patient trust

Medication safety directly influences the value of care patients receive. The trust patients place in healthcare providers demands meticulous cross-checking of allergies, contraindications, and potential drug interactions. A single medication error can compromise the quality and effectiveness of care delivered.

Recommendation (R)

Implementing electronic medication management systems (EMMS) is an evidence-based practice proven to reduce medication errors significantly. These systems automate dosage calculations, infusion rates, timing, and verification processes, leading to improved patient outcomes and cost savings (Westbrook et al., 2020). A controlled before-and-after study demonstrated that EMMS implementation halved the incidence of serious medication errors.

Alignment with High-Reliability Organization Principles

High-reliability organizations (HROs) aim for zero harm by maintaining a culture focused on safety and continuous improvement. One key HRO trait is a preoccupation with failure—actively identifying risks before adverse events occur and refining processes accordingly. EMMS adoption exemplifies this principle by enabling healthcare teams to detect potential medication errors early and continuously monitor outcomes for improvement. Such proactive change aligns with HRO goals and reduces harm.

Potential Barriers

Barrier	Description
Financial Costs	High initial investment and maintenance costs (~$285,000 over 15 years per hospital)
Staff Training and Adaptation	Need for extensive education and adjustment from paper-based to electronic systems

Interventions to Overcome Barriers

Phased Implementation: Hospitals can adopt EMMS gradually, prioritizing high-risk departments first, spreading costs over time and allowing incremental adaptation.
Comprehensive Training Programs: Offering dedicated training sessions outside of patient care hours improves staff confidence and competence before system “go-live,” reducing resistance and errors.

Shared Decision-Making Importance

Successful EMMS adoption requires collaboration among physicians, nurses, IT specialists, pharmacists, and patients. Physicians and nurses provide practical insights into system usability, while patient feedback can highlight areas affecting care experience. This inclusive approach promotes ownership, ensures value-based care, and supports sustainable improvements in patient safety.

Outcome Measurement

A quality improvement team should track medication error rates by department and severity before and after EMMS implementation. Indicators include total error reduction, decrease in severe errors, and long-term financial savings related to fewer adverse drug events.

Current Care Delivery Model and Impact of Recommendation

Care models vary by setting—for example, acute care often uses functional nursing with task delegation, while inpatient settings may utilize team nursing involving RNs, LPNs, and aides. Regardless of model, EMMS benefits all by speeding medication administration, enabling cross-checks for correct patient and dose, and alerting users to contraindications or allergies. This support reduces errors and supports nurses, including float or task nurses unfamiliar with specific patients.

Summary Table of SBAR Analysis

SBAR Component	Content
Situation (S)	Medication administration errors pose a significant safety risk affecting multiple patients across settings.
Background (B)	Thousands of deaths yearly due to medication errors; errors can occur at prescribing, transcription, dispensing, and administration stages; national safety standards emphasize patient ID verification and safe medication practices.
Assessment (A)	Errors harm patients, induce staff disciplinary actions, and burden organizations financially and reputationally; patient trust and care value are compromised.
Recommendation (R)	Implement electronic medication management systems to reduce errors, aligned with high-reliability organization principles; phased rollout and training recommended to overcome financial and staffing barriers; stakeholder engagement critical.

References

Tariq, R. A., Vashisht, R., Sinha, A., et al. (2023). Medication Dispensing Errors and Prevention. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/

The Joint Commission. (2021). 2021 Hospital National Patient Safety Goals. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/simplified-2021-hap-npsg-goals-final-11420.pdf

Westbrook, J. I., Sunderland, N. S., Woods, A., Raban, M. Z., Gates, P., & Li, L. (2020). Changes in medication administration error rates associated with the introduction of Electronic Medication Systems in hospitals: A multisite controlled before and after study. BMJ Health & Care Informatics, 27(3). https://doi.org/10.1136/bmjhci-2020-100170