Posted: July 14th, 2022

Medication Error

Medication Error
Medication Error
This is just rewrite to avoid plagiarism
A medication error is an error (of commission or omission) at any step along the pathway that begins when a
clinician prescribes a medication and ends when the patient actually receives the medication (Agency for Health
Care Research and Quality, 2019).
In a study conducted by Da Silva and Krishnamurthy (2016), they state that preventable medication errors
impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of
hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors are
an underreported burden that adversely affects patients, providers, and the economy. The study involved a 71-
year-old female who accidentally received thiothixene (Navane), an antipsychotic, instead of her antihypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm
including ambulatory dysfunction, tremors, mood swings, and personality changes and had multiple hospital
visits within the 3 months. Despite the many opportunities for intervention, multiple health care providers
overlooked her symptoms. Admission medication reconciliation (MED REC) revealed that she was taking
metoprolol, doxazosin, alprazolam, citalopram, and thiothixene (Navane) 10 mg twice daily. Upon review of her
pill bottles, it was found that her outpatient pharmacy accidentally dispensed Navane (an antipsychotic) instead
of Norvasc, and she dutifully took this medication for 3 months. The written prescription was deemed legible. A
diagnosis of thiothixene-related drug-induced Parkinsonism was made. Thiothixene was discontinued and her
clinical status improved.
Da Silva and Krishnamurthy (2018) note that important steps to prevent medication error include clear patient
instructions with indications for use on every prescription, utilization of EHR medication import (when
available) to review outpatient prescription history, and creating a culture within the medical field of error
discussion. Possibilities include medication teams who review admission and discharge reconciliations, team
rounding with a pharmacist, encouraging postgraduate trainees and faculty to question indications and utility of
medications, and distribution of national and institution data regarding errors, and adverse events. Mandatory
training should occur for those providers who fail to document and reconcile medications properly.
As a nurse practitioner it is important to monitor the patient especially when poor treatment response occurs or
unusual symptoms develop, it is imperative that a review of medications and pill bottle review be part of the
initial Assessment. I will implement and use multilevel safeguards, starting with error recognition. Medical error
was recently described as the third leading cause of death and only by creating a culture of humility,
communication, and teamwork can we learn from our mistakes and hope to decrease preventable errors.
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6/3/22, 4:33 PM Medication Error – Top Notch Nursing Papers | Top Notch Nursing Papers
https://topnotchnursingpapers.com/2022/05/21/medication-error/ 2/5
References
Agency for Health Care Research and Quality. (2019). Medication Errors and Adverse Drug Events. Retrieved
from https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events
Da Silva, B., Krishnamurthy, M. 92016). The alarming reality of medication error: a patient case and review of
Pennsylvania and National data. Retrieved from https://www.tandfonline.com/doi/full/10.3402/jchimp.v6.31758

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