Medication errors: understanding the risk

Abstract

There is much written in the literature on medication errors that suggests an individual is at fault or the system is to blame. This study reviewed a set of reported medication error data and compared it to a sample of literature on medication errors using a content analysis approach. The choice of this methodology was to note if a theme, "concept of risk reduction", or a reduction in possible harm to the patient, the staff member or the organization was central in the ideas being promulgated. The analysis of an acute tertiary hospital's significant event or incident data against a sample of medication error literature demonstrated two central themes or concepts. The first theme from the hospital data analysis was the failure to follow the organization's policy and process, primarily related to checking. The second theme was the poor verbal and written communication between staff members. Similar themes were noted in the literature. The hospital data and the literature also noted the organizational culture and processes were relevant to error occurrence but overall the findings from the hospital data suggested issues with individuals performance rather than organizational process.