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Capella 4000 Assessment 4

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    Capella 4000 Assessment 4

    Capella 4000 Assessment 4 Analyzing a Current Health Care Issue

    Student Name

    Capella University

    NHS-FPX 4000 Developing a Health Care Perspective

    Prof. Name



    Hospitals worldwide confront various problems related to patients’ safety and quality improvement. These problems are concerning because they negatively harm patients’ lives as well as impair hospitals’ reputations. Hence these issues require constant efforts to address them and overcome the challenges that they pose to the healthcare system. These problems include but are not limited to medication errors, patient falls, hospital-acquired infections, delayed treatment, and shortage of staffing. This scholarly paper covers the topic of medication errors as this is the most commonly found problem in the healthcare setting which requires constant interventions to improve health practices and ensure quality care is provided. 

    Medication Errors – An Important Healthcare Issue 

    According to the Food and Drug Administration (FDA), medication errors are described as preventable adverse incidents that are related to or involve medication (Center for Drug Evaluation and Research, 2019). These errors can happen to professionals as well as patients or their families. Since this paper highlights the issue at a healthcare organization, the focus remains specifically on medication errors performed by healthcare workers. 

    There are several studies conducted to analyze the worldwide data related to medication errors and their incidences. A study mentioned that approximately 237 million cases of drug-related errors have been recorded in England per year (Elliott et al., 2021). Another study conducted on the prevalence of medication errors showed a significant percentage of 30.5% of medication errors found in study participants. Furthermore, the types of errors were calculated that revealed 46.9% of errors were due to administering drugs at the wrong time. Non-approved drugs, omission error, and dose error were 25.4%, 18.5%, and 9.2% respectively (Shitu et al., 2020).

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    Medication errors not only cause health complications for the patients but can also lead to increased mortality rate and imposes a burden on the economy. The US Institute of Medicine stated that medical errors are the leading cause of approximately 44,000 to 98,000 deaths in the USA (Zirpe et al., 2020). Shitu and colleagues (2020) further state in their study that for 1.5 million people affected by medication errors, nearly $3.5 billion is the additional cost associated with the treatment annually which puts an economic burden of $42 billion on global healthcare systems (Shitu et al., 2020). 

    The information provided above helps to explicitly explain the presence of these drug-related errors in the healthcare systems worldwide, thus advocating the importance of immediately addressing the problem. Furthermore, these articles provide insight into implementing various quality improvement strategies to eradicate this concern from the hospitals so that patients’ health is preserved as well as the economic burden is alleviated. 

    Analyze the Problem – Medication Errors

    Since medication error is a widespread problem in the healthcare system which poses challenges for the healthcare professionals as well as the hospital administration, it is essential to completely understand the problem, analyze the associated root causes, identify the group of people involved, and highlight the significant impacts of the problem so that effective strategies can be developed after comprehensive understanding. 

    Definition of Medication Error

    The National Coordinating Council for Medication Error Reporting and Prevention defines medication errors are those avoidable events that lead to incorrect use of medication by doctors, nurses, or pharmacists which eventually causes harm to the patient’s health and life (Zirpe et al., 2020). 

    Root Causes of Medication Errors

    Certain factors that lead to these errors are poor healthcare practices (improper prescribing, inappropriate preparation of the drugs, mistakes while dispensing, and incorrect administration), poor quality of drug products, systematic errors (errors in electronic systems of medication prescription and administration), ineffective communication, undesirable distractions and lack of education (Izadpanah et al., 2018; Tabatabaee et al., 2022).

    Another study by Manias and colleagues (2021) presents specific categories of factors that lead to medication errors. Some of these categories are personal factors which include healthcare workers’ incomplete knowledge about the medications, burnout, and fatigue due to excessive workload which is another environmental trigger. Moreover, some communication factors like incomplete handover, verbal orders which are inappropriately comprehended and unimportant conversations during the medication process (Manias et al., 2021).  

    People Involved in Medication Errors 

    Medication errors in healthcare organizations are committed by either doctors, pharmacists, or nurses. This group of people is mainly involved in the medication process and thus every individual member from these professions is trained according to their roles. 


    Physicians are the primarily responsible group of people who are involved in medication prescribing errors. A study based in a tertiary hospital in the US revealed that almost 54% of medication errors happen at the prescribing stage (Anzan et al., 2021). Another study conducted in Tehran teaching hospitals concluded that out of 50.5% of medication errors, 22.6% are due to mistakes from prescribers (Izadpanah et al., 2018). 


    The prevalence of medication dispensing errors by pharmacies in the US and the UK ranges from 0.04 % to a maximum of 24% (Chand et al., 2022). Dispensing is one of the important stages of the medication process and should be done vigilantly. 


    The medication process ends with the administration which is a major responsibility of the nurses. Research identifies that 68% of these errors are identified at the administration stage (Mulac et al., 2021). The type of errors that nurses may commit is administering the drug to the wrong patient, wrong dose, incorrect time, use of routes that are not applicable, and may not properly document (Wondmieneh et al., 2020). 

    Since healthcare professionals are mainly involved in committing medication errors due to poor practices and lack of training, the administration in the hospital must find effective solutions to address the issue. 

    Potential Solutions for Medication Errors

    Addressing medication error issues in a hospital is significant as if these errors are ignored, the potential consequences will be negative impacts on patients’ health (aggravation of the health conditions), increased readmission rates in the hospital which will lead to the financial burden on the patients as well as the hospital. Hospital Readmissions Reduction Program (HRRP) mentions that hospitals with higher readmission rates are giving heavy financial punishments hence hospital administration should work to improve patients’ safety to reduce recurrent admissions (Gai & Pachamanova, 2019). Moreover, medication errors show poor consequences on healthcare professionals as well evident in stress, diminished self-confidence, and burnout which ultimately lead to poor care quality (Ahmed et al., 2019). 

    There are various evidence-based strategies recommended for preventing medication errors. The most useful actions are, a) proper training for healthcare professionals, b) education for patients, and c) introduction of medication software and bar-coded systems.

    Training for Healthcare Professionals

    Medication safety training programs are essential to continuously evaluate the knowledge gaps of healthcare professionals and assist them in improving their knowledge. Healthcare professionals must be educated about standard guidelines of the medication process for example rights of medication administration framework for nurses. For this purpose handbooks and pamphlets should be created so that information remains handy and healthcare professionals can always seek guidance when needed (Abukhader & Abukhader, 2020). Further research recommends that nurses and other healthcare professionals are educated according to safety competencies so that standard practices are incorporated and patients’ safety is ensured (Watanabe et al., 2021). 

    Educating Patients

    Educating patients related to medications is essential as in case of any wrong administration, patients can stop healthcare professionals before committing the error. Moreover, information about the side effects of certain drugs helps patients to identify abnormal signs so that immediate actions can be taken to prevent complications. Patients’ involvement increases patients’ safety by enhancing their health literacy and compliance with the health regimen which eventually decreases the chances of medical errors (Kim et al., 2020). 

    Introduction of Technologies

    The introduction of new technologies to reduce medication error incidences is essential as it will help avoid human errors. Research recommends two important systems – electronic medication record (EMR) system which is linked with the physician order entry system. It is elaborated that the medications which are prescribed using software minimize the chances of errors as the well-established system generates alarms for specific errors (Kenawy & Kett, 2019). Another technology is bar-coded medication administration. A barcode scanner connected with the EMR system allows nurses to overcome the complexity of the process and follow the rights of medication effectively (Naidu & Alicia, 2019). 

    Ethical Implications of the Recommended Solutions 

    There are mainly four ethical principles that keep great importance in healthcare practices – autonomy, beneficence, non-maleficence, and justice. Similarly, in every healthcare issue, these ethical principles are applied so that ethically defined care is provided to the patients. 

    • Autonomy: Autonomy in medical practices is defined as the right of the patient to make informed decisions about their health (Buka, 2020). It follows in terms of medication provision and medication errors as well. If a medication error is already committed, healthcare professionals should inform patients. Hence the solution to educate patients about medication use comes under the ethical principle of patients’ autonomy. 
    • Beneficence: it is the foremost duty of healthcare professionals to perform their practices according to the ethical principle where patients’ benefit is given priority. Incidences of medication errors oppose this ethical principle hence it is essential that healthcare professionals are adequately trained and appropriate methods are used to ensure patients are in safe hands (Vemuri et al., 2022). The ethical principle of non-maleficence is correlated with beneficence as it says to not harm the patient which means ensuring safe practices. 
    • Justice: The provision of safe and quality care promotes a culture of equality for all. Justice is the ethical principle that focuses on the fair distribution of healthcare facilities and resources (Varkey, 2020). Thus, hospital administration needs to involve governmental bodies in finding solutions to medication errors so that all the solutions are implemented as standard throughout the country to ensure every individual receives quality care. 


    Medication errors are a significant healthcare issue that must be immediately addressed using appropriate measures to provide quality care and maintain patients’ safety. Introduction of technologies and training staff according to the standards are the two most useful solutions to overcome this challenge. However, further involvement of governmental bodies and policymakers is recommended to ensure safe and standard practices are followed. 


    Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal of Biosciences and Medicines8(06), 135.

    Ahmed, Z., Saada, M., Jones, A. M., & Al-Hamid, A. M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PloS one14(5), e0217023. 

    Anzan, M., Alwhaibi, M., Almetwazi, M., & Alhawassi, T. M. (2021). Prescribing errors and associated factors in discharge prescriptions in the emergency department: A prospective cross-sectional study. PLOS ONE16(1). 

    Buka, P. (2020). Consent to treatment, patient autonomy. Essential Law and Ethics in Nursing, 65–84. 

    Center for Drug Evaluation and Research. (2019). Working to reduce medication errors. U.S. Food and Drug Administration. Retrieved March 25, 2023, from

    Chand, S., Hiremath, S., Shastry, C. S., Joel, J. J., Krishna Bhat, C. H., & Dikkatwar, M. S. (2022). Incidence and types of dispensing errors in the pharmacy of a tertiary care charitable hospital. Clinical Epidemiology and Global Health18, 101172.  

    Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30(2), 96-105. 

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    Gai, Y., & Pachamanova, D. (2019). Impact of the medicare hospital readmissions reduction program on vulnerable populations. BMC Health Services Research19(1).  

    Izadpanah, F., Nikfar, S., Imcheh, B.F., Amini, M., & Zargaran, M. (2018). Assessment of frequency and causes of medication errors in pediatrics and emergency wards of teaching hospitals affiliated to Tehran University of Medical Sciences (24 hospitals). Journal of Medicine and Life11(4), 299–305. 

    Kenawy, A. S., & Kett, V. (2019). The impact of electronic prescription on reducing medication errors in an Egyptian outpatient clinic. International Journal of Medical Informatics127, 80-87. 

    Kim, Y.-S., Kim, H. S., Kim, H. A., Chun, J., Kwak, M. J., Kim, M.-S., Hwang, J.-I., & Kim, H. (2020). Can patient and family education prevent medical errors? A descriptive study. BMC Health Services Research20(1). 

    Manias, E., Street, M., Lowe, G., Low, J. K., Gray, K., & Botti, M. (2021). Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: A retrospective clinical audit. BMC Health Services Research21(1), 1-13.

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    Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy, 28(e1), e56-e61. 

    Naidu, M., & Alicia, Y. L. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health11(05), 511–526. 

    Shitu, Z., Aung, M. M., 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).  

    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(1). 

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    Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice30(1), 17–28. 

    Vemuri, N., Sneed, K., & Pathak, Y. (2022). Medication errors: An ethical analysis. Biomedical Journal of Scientific and Technical Research.

    Watanabe, Y., Claus, S., Nakagawa, T., Yasunami, S., & Teshima, M. (2021). A study for the evaluation of a safety education program me for nursing students: Discussions using the QSEN safety competencies. Journal of Research in Nursing26(1-2), 97–115.  

    Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(1). 

    Zirpe, K.G., Seta, B., Gholap, S., Aurangabadi, K., Deshmukh, A. M., Wankhede, P., Suryawanshi, P., Vasanth, S., Kurian, M., Philip, E., Jagtap, N., & Pandit, E. (2020). Incidence of medication error in critical care unit of a tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine24(9), 799–803.