Systems and Organizational Failures Often Result in Patient Harm Caused by Medication Errors

When a person needs to take medication to treat a condition or ailment, that patient typically does so with the good faith belief that the medication is going help rather than cause greater harm. Unfortunately, medication errors can and do occur, and when they do, the patient is often left facing injuries. These errors occur for many reasons. In some cases, the individual health care provider overseeing the patient’s care may make a mistake. This may include a physician, nurse, or pharmacist. Similarly, medication errors may occur when the patient themselves do something to cause the error.

Common Examples of System and Organizational Failures Leading to Medication Errors

When an error occurs during the chain-of-events leading up to the administration of medication to a patient, this is known as a systemic or organizational failure. These types of failures can happen for a wide variety of reasons. Examples of systemic or organizational failures that can lead to medication errors include the following:

1. The patient information is unavailable or inaccessible. As a result, the person administering the medication may not have access to the patient’s health status, illnesses, laboratory test results, current medications list, or known drug allergies. The patient may receive the wrong medication or the wrong dosage of a medication due to this lack of information. The health care provider may also be unable to crosscheck the medication with the patient’s history or current medical status to watch for warning signs of potential harm.
2. The patient’s medication orders are handwritten and illegible, contain misspellings, contain abbreviations, are incorrect, or are incomplete. When any of these scenarios arise, the persons responsible for assembling and administering the medication may be unaware that they are taking actions that could lead to harm in the patient.
3. The person in charge of administering or gathering the medication lacks sufficient knowledge about the medication at hand. This may lead to the person administering an improper dose of the medication or failing to catch or look for potential adverse interactions between medications.
4. The process for administering the drug is faulty. For example, the medication may be given at the incorrect time, via an incorrect route, or the wrong medication may be given as opposed to the medication that was prescribed by the attending physician. Similarly, medication may be administered to the wrong patient.

As described in the examples above, a system or organization failure that leads to harm caused by medication errors results from the quality of the process in place with regard to medication ordering and administration. In fact, medication errors may occur more frequently as a result of poorly designed processes or faulty systems rather than the incompetence or mistake of medical practitioners.

How System Failures Can Be Avoided With Regard to Medication

1. Hospitals and other health care facilities can include a pharmacist on medical rounds. When this occurs, errors can often be significantly reduced.
2. Guidelines and protocols can be standardized across various fields. For example, the specialty of anesthesia has adopted these standardized guidelines and has since significantly reduced the error rates involved in the anesthesia process.
3. The equipment used in hospitals and other health care facilities can be standardized based on the type of care being administered. The more standards that are put in place, the lesser the likelihood of an error occurring.
4. Technology can be incorporated into systems and processes to help reduce the chance of a medical error occurring. For example, some hospitals now use handheld, wireless computer technology and barcoding. As a result, errors are dramatically reduced.

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