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NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

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Capella University

NHS-FPX 4000 Developing a Health Care Perspective

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Analyzing a Current Health Care Problem or Issue

Patient safety is vital in the healthcare sector, ensuring the well-being of individuals by preventing errors, minimizing risks, and promoting a culture of continuous improvement in healthcare practices. Medication errors are one such issue that compromises patient safety. This paper aims to provide a comprehensive overview of medication errors, encompassing their definition, prevalence, causative factors, solutions to address the issue, and ethical implications of those solutions. By delving into the intricacies of medication errors, this paper aims to empower healthcare professionals and policymakers to implement effective interventions that safeguard patient well-being.

Elements of the Problem

Medication errors significantly threaten patient safety, encompassing mistakes during prescribing, dispensing, and administering. Such errors can result in adverse health outcomes and life-threatening complications for the patients. According to a study by Tabatabaee et al. (2022), medication errors are considered the third leading cause of mortality in the United States. In the U.S., it is estimated that medication errors influence approximately 1.5 million people yearly, with a treatment cost of $3.5 billion. Globally, this economic impact exceeds $42 billion annually (Shitu et al., 2020).

According to the World Health Organization, medication errors are resulting in single mortality every day in the United States. Thus, the organization emphasizes the need to address the issue using efficient methods to ensure patients remain safe during their healthcare journeys (Naseralallah et al., 2023). Several factors, such as inadequate communication between healthcare providers, obscured prescriptions, look-alike and sound-alike drugs, interruptions during medication management, and lack of trained staff, are leading causes of preventable medication errors. Other systemic issues, for instance, unavailability of standardized protocols, technological insufficiencies, and excessive workload, may aggravate such errors. Therefore, there is a significant need to address the issue and identify effective solutions. 

The scholarly resources presented above are credible and relevant to the topic of this assessment – medication errors. These resources fulfill the CRAAP (currency, relevance, authority, accuracy, and purpose) criteria, an evaluative method for recognizing credible resources. Moreover, these resources provide explicit information about medication errors, their prevalence, and their impact on patients. Such information is essential for healthcare professionals to take adequate measures to eradicate the problem and maintain patient safety. 


The specific incident that this assessment focuses on is the incorrect administration of an antibiotic to the wrong patient. This event was observed during clinical orientation, where a nurse administered a Piperacillin and Tazobactam antibiotic combination to an allergic patient. The patient immediately survived an anaphylaxis reaction, ultimately resulting in an increased length of hospital stay. This issue is important to a baccalaureate-prepared nurse because medication administration is vital to nurses’ job descriptions. A nurse must be adequately trained and competent to prevent errors and improve patient safety through proper medication handling and management. 

Definition and Causes of the Problem

Medication errors are those stoppable incidents that could result in patient injury due to inaccurate medication management by healthcare professionals or patients (Shitu et al., 2020). The above mentioned incident results from several risk factors, such as nurses’ lack of concentration while administering medication. This lack of concentration can be because of unnecessary interruptions in clinical areas. A study reveals that 91% of nurses perform medication errors due to distractions during medication administration (Raja et al., 2019). Another cause of such an error is the need to follow the rights of medication administration: the right patient, the right drug, the right time, the right dose, and the right route. The Five Rights of Medication Administration framework provides standardized guidelines for nurses to follow when administering medications to ensure patient safety and correct administration of drugs (Hanson & Haddad, 2022). 

Who is Involved? The Groups Impacted

The patient is the one who is affected by this specific incident the most. The error became harmful as the patient was allergic to PipTazo. The incorrect administration resulted in allergic reactions, eventually increasing hospital stay. It is estimated that 5% of hospital admissions are due to adverse drug events resulting from wrong medication administration. These increased hospital admission rates and extended length of hospital stay may incur additional healthcare costs for the patients and the organization (Alahmadi et al., 2022). The mistaken nurse will be the next to suffer the consequences. These effects include stress, anxiety, reduced performance abilities, lack of confidence to perform the role in the future, and job dissatisfaction and burnout. Finally, the relevant medication error issue impacts the healthcare organization, resulting in lower performance and a damaged industry reputation (Rodziewicz et al., 2023). 

Considering Options

Several evidence-based solutions are presented in the literature studies to combat the challenge of medication errors and preserve patient safety. One potential solution is introducing a Barcoding Medication Administration (BCMA) system. This technology utilizes barcodes to administer medications accurately, improving patient safety in healthcare settings. This system is established on the Five Rights of Medication Administration framework, where drug and patients’ medical details are scanned to verify that the right patient receives the right drug through the correct method. Thompson et al. (2018) advocate the effectiveness of the BCMA system, as the results were improved by 48.3% after its implementation. Pharmacist-led medication reconciliation is another possible solution to address these preventable errors.

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

This strategy involves pharmacists comprehensively reviewing patients’ medication charts and identifying the discrepancies. Such assessments are essential to identify identical medication orders, contraindications in patients’ cases, and different drug interactions (Studer et al., 2023). Medication reconciliation aims to administer appropriate drugs, modify regimens according to the needs, and educate patients to make informed decisions. 

The possible consequences of ignoring medication errors are increased morbidities and mortality rates. As discussed earlier, medication errors can lead to adverse drug events and harmful reactions in patients (Alrabadi et al., 2021). These outcomes can result in serious health complications, disability, or even death. Additionally, as demonstrated in the specific case scenario, it can lengthen the hospital stay, ultimately raising healthcare costs (Rodziewicz et al., 2023). Finally, the organization and the providers may face different legal ramifications due to their negligent actions, which could harm their reputation and put additional strain on resources. 

Solution and Implementation 

The most effective solution, specifically in the case scenario, will be implementing a barcode medication administration (BCMA) system. Implementing this solution involves a holistic approach using both human and technological resources. A systematic literature review concluded that the bar-coding medication administration system minimizes medication errors, especially errors related to the five rights of medication administration (Hutton et al., 2021). The implementation plan for the specific case scenario includes a thorough assessment required to identify the areas of conflict. Then, an interprofessional team must gather to develop a comprehensive implementation plan that outlines timelines, resource allocation, communication strategies, and the list of requirements.

An effective technology is selected, aligning with the organizational needs and current technological infrastructure. The next step is to train healthcare professionals, especially nurses, about effective system utilization. Lastly, implement BCMA in a pilot area to test functionality and identify problems to refine the processes and optimize the system’s effectiveness. Along with all this, monitoring the implementation through evaluation protocols to track BCMA system performance is also imperative. This ongoing monitoring enables the organization to maintain effectiveness and improve patient outcomes (Thompson et al., 2018). 

Ethical Implications 

Considering the ethical considerations, implementing BCMA upholds several ethical principles. The ethical principles of beneficence and non-maleficence align with providing safe and danger-free care (Cheraghi et al., 2023). Introducing BCMA to improve patient safety by reducing medication errors is connected with these ethical principles. Achieving these outcomes requires adequate staff training, and supervision should be ensured for proper use and preventing impending errors. Similarly, to uphold the principle of autonomy, patients should be informed and educated about BCMA technology and its purpose so that they can make informed decisions for their healthcare. Lastly, the BCMA implementation is planned to be equitable, ensuring all patients receive medications through this process, regardless of their socioeconomic status and background. 


In conclusion, medication errors are a significant healthcare problem, requiring immediate and effective solutions. The main risk factors of these errors include individualized factors like workload and inadequate competencies and systemic issues such as technological deprivation and environmental disruptions. Other factors include lack of communication, inadequate standardized guidelines, lack of attention, and obscured prescriptions. Implementing a barcoding system and pharmacist-led medication reconciliation are the best possible solutions for these errors. The chosen solution for a particular case scenario is BCMA implementation, which requires a comprehensive implementation plan while considering ethical principles. The purpose is to enable safe practices to maintain patient safety and improve organizational performance. 


Alahmadi, Y. M., Alharbi, M. A., Almusallam, A. J., Alahmadi, R. Y., & Alolayan, S. O. (2022). Incidence of medication errors in King Fahad Hospital Madina, Saudi Arabia. Brazilian Journal of Pharmaceutical Sciences58, e201196. https://doi.org/10.1590/s2175-97902022e201196 

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025 

Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing22, 89. https://doi.org/10.1186/s12912-023-01246-4 

Hanson, A., & Haddad, L. M. (2022). Nursing rights of medication administration. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK560654/

Hutton, K., Ding, Q., & Wellman, G. (2021). The effects of bar-coding technology on medication errors: A systematic literature review. Journal of Patient Safety17(3), e192. https://doi.org/10.1097/PTS.0000000000000366 

Naseralallah, L., Stewart, D., Price, M., & Paudyal, V. (2023). Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: A systematic review. International Journal of Clinical Pharmacyhttps://doi.org/10.1007/s11096-023-01626-5 

Raja, Badil, Ali, S., & Sherali, S. (2019). Association of medication administration errors with interruption among nurses in public sector tertiary care hospitals. Pakistan Journal of Medical Sciences35(5), 1318–1321. https://doi.org/10.12669/pjms.35.5.287

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499956/ 

Shitu, Z., Aung, M. M. T., Tuan Kamauzaman, T. H., & Ab Rahman, A. F. (2020). Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia. BMC Health Services Research20(1), 56. https://doi.org/10.1186/s12913-020-4921-4 

Studer, H., Imfeld-Isenegger, T. L., Beeler, P. E., Ceppi, M. G., Rosen, C., Bodmer, M., Boeni, F., Hersberger, K. E., & Lampert, M. L. (2023). The impact of pharmacist-led medication reconciliation and interprofessional ward rounds on drug-related problems at hospital discharge. International Journal of Clinical Pharmacy45(1), 117–125. https://doi.org/10.1007/s11096-022-01496-3 

Tabatabaee, S. S., Ghavami, V., Javan-Noughabi, J., & Kakemam, E. (2022). Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: A retrospective study of medical records. BMC Health Services Research22, 1420. https://doi.org/10.1186/s12913-022-08864-9 

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

Thompson, K. M., Swanson, K. M., Cox, D. L., Kirchner, R. B., Russell, J. J., Wermers, R. A., Storlie, C. B., Johnson, M. G., & Naessens, J. M. (2018). Implementation of barcode medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes2(4), 342–351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001 

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