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

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


    Capella university

    NHS FPX4000 Developing a Health Care Perspective

    Prof. Name


    Analyzing a Current Health Care Problem or Issue  

    Medication errors can be described as a failure in the medication management process. It can be due to improper prescription, administration, or inaccurate medication records that can potentially damage the patient, resulting in poor health outcomes (Mosisa et al., 2022). This academic paper addresses a significant healthcare concern: medication errors within the healthcare system. The growing incidences of medication errors have developed my interest in this topic. As a healthcare provider, I must prioritize initiatives to prevent these errors in my nursing practice. In the professional context, I have observed various medication errors in my organization where healthcare providers administered incorrect medication doses, misread prescriptions, and neglected possible drug interactions, leading to severe patient complications. Thus, it is essential to tackle the underlying causes and put strong protections in place to reduce medication errors and ensure patient safety.

    Medication Errors as a Healthcare Issue

    Globally, medication errors cause morbidity, mortality, and adverse economic effects. The prevalence of medication errors may be correlated with the involvement of healthcare professionals such as medical experts, unit assistants, physicians, pharmacists, and nurses. In USA Intensive Care Units (ICUs), it has been observed that 42% of medication errors are crucial to continuing treatment, while 19% are life-threatening (Alrabadi et al., 2021). One-quarter of all healthcare errors are related to medication errors, including prescribing, transcribing, dispensing, administering, and monitoring. The World Health Organization (WHO) estimates that drug errors cost the global economy $42 billion yearly, or 0.7% of all health spending (Manias et al., 2020).

    According to the study by Alqenae et al. (2020), Medication errors (MEs) and adverse drug events (ADEs) are common and create severe risks to patients’ safety after discharge from the hospital. According to the review, over half of adult and senior patients have at least one medication error after discharge, with one in every five having one or more ADEs. Antibiotics, antidiabetics, analgesics, and cardiovascular medicines are the most typically related medication classes with ADEs.

    This highlights the significance of addressing medication safety during care transitions, and further research is required to find effective strategies to lessen these risks. These articles are valuable because they analyze the global significance of medication errors, their impact on patient safety, and the economic consequences. They provide specific statistics and insights into the prevalence and severity of medication errors. They highlight the need for interventions and research to mitigate these risks and improve healthcare outcomes.

    Analyze the Problem or Issue in Medication Error

    Medication errors are preventable mistakes that can result in incorrect medication use or harm to the patient. It can occur at any stage of the healthcare process, from prescribing to administration, and involves professionals, patients, and consumers. Medication errors in the healthcare system involve several groups. Prescription, preparation, and administration of pharmaceuticals are the responsibility of doctors, nurses, pharmacists, and other healthcare professionals. Patients also have an essential role in misinterpreting drug instructions, insufficient medical history disclosure, or difficulty adhering to complex prescription schedules.

    Various contributory human factors cause medication errors (MEs) in hospital pharmacies. These factors include individual elements like fatigue and emotional stress, organizational aspects such as support systems and communication, task-related challenges like high workload during specific shifts, and team dynamics, including interprofessional communication. It is crucial to deal with these human factors for enhancing patient safety within the framework of hospital pharmacy settings. (Faraj et al., 2020). Another study by Kuitunen et al. (2020) describes avoiding safety procedures for high-alert drugs, drug knowledge gaps, calculation errors, double-checking lapses, and LASA medication confusion as systemic causes of medication errors. Addressing these flaws and standardizing processes are critical for improving medicine safety during administration, prescribing, and preparation.

    Discusses Potential Solutions for Medication Errors

    Medication errors require a wide range of approaches addressing their underlying causes. Potential solutions to ensure positive outcomes include integrated computerized pharmacy systems. Additionally, staff management and a process improvement approach are crucial. These solutions collectively aim to improve patient safety and reduce the risks associated with medication errors.

    Integrated Computerized Systems at Pharmacies

    Look-alike or sound-alike (LASA) errors constitute a significant part of total medication errors. These types of errors can create severe harm to patient health and safety. The approaches and solutions to reduce LASA include. To reduce medication-related errors, minimize interruptions, use ‘Tall Man lettering,’ and leverage barcode technology. One potential solution is using the technology of barcode medication delivery to ensure that the given medicine is correct.

    Healthcare providers should be informed about LASA medication combinations and computerized physician order entry systems with notifications should also be used to minimize errors (Baryan et al., 2020). The pros and cons of this solution are that proactive measures such as technology integration and healthcare provider education enhance patient safety while neglecting LASA errors, which can lead to patient harm, legal issues, and increased healthcare costs. 

    Management of Staff

    Potential solutions for reducing hospital medication errors include training junior staff in medication prescribing and administration. Training should focus on being vigilant during duty hours to mitigate these errors. In these trainings, hospital management should also address environmental issues and workload management for new and old nurses. Furthermore, interdisciplinary collaboration and curriculum evaluations on pharmaceutical safety can help avoid these errors (Isaacs et al., 2020). The pros and cons are that training junior staff can improve medication safety through increased vigilance, addressing environmental challenges, and fostering interdisciplinary collaboration. Ignoring this solution can create stress and anxiety within nursing professionals, which can enhance the chance of mistakes being made by nurses.

    Process Improvement Approach

    The implementation of Lean Six Sigma (LSS) in a =Thai hospital’s inpatient pharmacy was investigated by Trakulsunti et al. (2022) for the dispensing process. Some of the LSS tools used were cause-and-effect diagrams and brainstorming control charts. The study yielded significant improvements in the medication process. It streamlined the medication process, reduced dispensing errors, and improved overall patient safety. Middle management’s active involvement, leadership, and problem-solving skills can ensure effective LSS implementation to reduce medication errors. The pros and cons are that these process improvement approaches are helpful in pharmacy practices, and ignoring them can increase the factors responsible for medication errors.

    Ethical Principles of Recommended Potential Solutions

    In addressing medication errors, the core ethical principles of beneficence, nonmaleficence, autonomy, and justice must be at the forefront of any proposed solution. Implementing Lean Six Sigma (LSS) in pharmacy practices emphasizes beneficence by enhancing patient safety. It adheres to nonmaleficence by pinpointing and rectifying medication error causes, as Ahmed et al. (2022) demonstrated. Autonomy is championed by employing precise computerized prescriptions and “tall man” lettering, with Heck et al. (2021) underscoring their effectiveness in reducing errors, particularly with look-alike sound-alike (LASA) drugs.

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

    These methods empower patients, granting them clarity on their medications and promoting informed decision-making. Upholding justice requires that all patients receive timely and precise treatments. Hence, consistent nurse training, as endorsed by Wondmieneh et al. (2020), along with clear medication management guidelines and well-distributed workloads, is pivotal.

    For the successful implementation of these solutions, a multipronged approach is essential. This encompasses specialized training programs for healthcare professionals in LSS tools, computerized systems, and tall man letters. The commitment of resources is equally crucial, with investments in advanced tech solutions like computerized prescription systems. Gaining leadership’s support ensures seamless system integration while emphasizing the importance of periodic reviews to refine and optimize the process. Moreover, after implementation, regular audits are pivotal to ensure continued alignment with the aforementioned ethical principles and to gauge the effectiveness of these interventions in real-world settings.


    Medication errors are a substantial global healthcare problem, resulting in adverse patient outcomes, economic burdens, and risks to patient safety. These errors are multidimensional, including various healthcare personnel, societal concerns, and human factors. Potential solutions include Medication Safety Enhancement Systems, staff training, and Lean Six Sigma implementation, all of which strive to address these issues and improve patient safety. These methods support reducing prescription errors and fostering fair healthcare delivery by adhering to ethical concepts.


    Ahmed, S., Hawarna, S., Alqasmi, I., Mohiuddin, M., Rahman, M. K., & Ashrafi, D. M. (2022). Role of Lean Six Sigma approach for enhancing patient safety and quality improvement in the hospitals. International Journal of Healthcare Management, 1–11.  

    Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: A systematic review. Drug Safety, 43(6).  

    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 Research, 12(1), 78–86.  

    Faraj Al-Ahmadi, R., Al-Juffali, L., Al-Shanawani, S., & Ali, S. (2020). Categorizing and understanding medication errors in hospital pharmacy in relation to human factors. Saudi Pharmaceutical Journal, 28(12).  

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

    Heck, J., Groh, A., Stichtenoth, D. O., & Krause, O. (2021). Proposal of a tall man letter list for German-speaking countries. European Journal of Clinical Pharmacology, 77.  

    Isaacs, A. N., Ch’ng, K., Delhiwale, N., Taylor, K., Kent, B., & Raymond, A. (2020). Hospital medication errors: A cross-sectional study. International Journal for Quality in Health Care, 33(1).  

    Kuitunen, S., Niittynen, I., Airaksinen, M., & Holmström, A.-R. (2020). Systemic causes of in-hospital intravenous medication errors. Journal of Patient Safety, 17(8), 1.  

    Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1), 1–29.  

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

    Mosisa, B. (2022). Assessment of medication errors in emergency ward at Nekemte Referral hospital, West Ethiopia. Journal of Biomedical Science, 4(1).  

    Trakulsunti, Y., Antony, J., Edgeman, R., Cudney, B., Dempsey, M., & Brennan, A. (2021). Reducing pharmacy medication errors using Lean Six Sigma: A Thai hospital case study. Total Quality Management & Business Excellence, 33(5-6), 1–19.  

    Wondimeneh, 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 Nursing, 19(4), 1–9.