Study On Medication Errors, Causes And Prevention

Medication errors are defined as any mistake or false judgment in prescription, dispensing or administering medication, thus it may be a doctor’s, a pharmacist’s or a nurse’s mistake.

It is obvious that as a practicing first-line manager, your own success is more likely if you use your talents (strengths) to their full extent to exploit the opportunities that present themselves to you. Also, it’s important to understand your weaknesses so that you can manage them out of your daily work activities and thereby also eliminate any threats which may affect your potential to progress.

SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis (Stanford Research Institute 1960-1970) is a useful technique to identify and analyse, in a proactive manner, these four areas. Not only that, but it also

provides a good framework for reviewing your own personal development needs and

enables you to work on your personal strengths and abilities to distinguish yourself from your peers and hence forward your career

My own personal SWOT analysis has been appended to this assignment (see Appendix A).

Own Learning Style(s) Identified

Honey and Mumford (H&M) use the terms “activist”, “reflector”, “theorist” and “pragmatist” to represent the four key learning styles (or preferences). These correspond to stages in the learning cycle and are based on earlier work by David Kolb (and indeed are used interchangeably by some authors with the terms in the Kolb model). Both models are particularly interesting from the perspective that they offer a way to understand people’s different learning styles but also explain a cycle of experimental learning which can be applied to everyone.

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The four H&M key stages and styles are typically presented at north, east, south and west on a four-stage cyclical flow diagram. This actually expresses a four stage “cycle of learning” in which “having an immediate or concrete experience” provides a basis for “reviewing/reflecting on the experience”. These reflections are assimilated into “conclusions from the experience” producing implications for action which enables the “planning for the next step”, i.e. the creation of a new experience.

In theory, the learner should visit all four points of the diagram – i.e. a cycle of experiencing, reflecting, thinking and acting.

They, and their relationship with Kolb’s learning styles, are explained in the Table A below:

Table A -Comparison of H&M Learning stages/styles with Kolb learning style

Kolb’s Learning Style

H&M Learning Style/Stage

Preferred learning opportunity

Personality characteristics of learning style


Having an Experience/Activists

Practical, hands on

“Here and now”;

seek challenge and immediate experience;

Bored by implementation


Reviewing the experience/ Reflectors

Gather information, consider and analyse

Stands back;

Thoughtful; listens before speaking


Concluding from the Experience/ Theorists

Logical approach, gathers facts to form theories

Rational, objective, dismisses subjectivity


Planning the next steps /Pragmatists

Seeks new concepts, problem solving

Likes quick decisions, bored with long discussions

Most people naturally prefer a certain single different learning style. Various factors can influence this and Kolb defined 3 stages of a person’s development and suggests that the integration of the four different learning styles improves as a person progresses through the development stages.

I have completed an H&M Learning Style Questionnaire and my preferred learning styles are Theorist and Pragmatist. This means that I have a preference for a concise and logical approach to learning. For me, ideas and concepts are more interesting than people. I do require a good, clear explanation; however, one slight difference to this learning style is that I like to see that the theory can work in a practical situation as well.

I enjoy technically related tasks such as gathering and understanding wide-ranging information and trying to organise it in a logical format. In a formal learning situation, my preferences are reading and lectures and having time to consider things. I like to solve problems and make decisions by finding answers to questions.

This was not particularly surprising because my job role as an Assurance Specialist involved in auditing actually demands a logical style of approach to deliver work effectively. Furthermore, problem solving is also a key skill for me in advising teams on how to resolve issues with their management processes.

Analyse Learning and Development Options and Identify Barriers and Support mechanisms

Two learning/development options – one for self, one for organisation

My personal SWOT analysis identified two development options as follows:

To improve my “soft” skills – such as assertiveness, communication and the effectiveness of my decision making. This would help in meeting the needs of the organisation and of the needs of my immediate team.

To gain a better understanding of how Environmental Management is applied by Network Rail at a Project level. This would help me to gain an insight as to how I could apply some of the information I learnt on my Institute of Environmental Management (IEMA) course in a practical scenario.

I have added both of these onto a Personal Development Plan, which is attached as Appendix C to this assignment.

In terms of development opportunity (1), I could make use of the many e-learning tools available via the Network Rail Intranet site as well as obtaining support from my line manager to check my progress as well as him giving me tasks which will help to develop my soft-skills.

I could monitor the success of this personal development through regular (once a month) one-to-ones with my line-manager and via my 6-monthly performance reviews. Listening and learning from what has worked well for him in the past would align itself well with the pragmatic approach I prefer to learning.

With respect to my own personal development opportunity (2), there is a course offered through Network Rail about Environmental Management within Projects. I have booked a place on this course and intend to follow it up by conducting audits on Environmental Management across Infrastructure Projects as part of the 2010-11 National Core Audit Programme. In this way, I shall be able to speak to Environmental Specialists who apply Environmental Management techniques as part of their daily activities an gain a deeper understanding of what is involved.

Identify Barriers to learning and how to overcome them

Some potential barriers which could prevent or slow down my progress are time-constraints, distractions and issues with the suitability of e-Learning to my own learning style.

These barriers could be overcome by planning a “time-out for learning” within my weekly schedule and ensuring that I commit to not allowing any work activities to interfere with it.

I’m unsure as to whether e-learning will complement my learning style because the courses do not present practical situations to apply what has been learnt. However, perhaps regular feedback sessions and suitable tasks set by my line-manager may serve to complement the e-learning courses.

Considering the Environmental Management training I have identified, after completing the course, I will need to liaise with the staff drawing up the National Core Audit Programme so that I can be included for the Environmental Section of at least 2 of the audits across the Investment Projects portfolio. The auditing aspect will require me to make careful preparation before visiting the Programme so that I have a full awareness of how they are managing the Environment. This could involve looking at their Environmental Management Plan in detail and compiling a series of relevant questions before I make the visit. Both the training and my IEMA qualification should enable me to do this and carry out the audit effectively.

Support mechanisms for self-development

I would look to support from my line-manager and team members through the use of formal (1-2-1s) and ad-hoc reviews of my progress. Regular teleconferences or face-to-face meetings with members of the cohort who attended the same “Leading and Managing Teams” course could also be set up, where we could discuss our own personal progress and problems. These may prove to be extremely beneficial from a learning perspective for all concerned. I would also like to involve the Investment Projects Environment Manager and Environmental Specialists from the Programmes from the perspective of them being there to provide expert advice on technical questions.

Two other support mechanisms which suit my learning style are testing and feedback. I am most comfortable with regularly testing my new skill sets – as demonstrated with the Environmental training – taking what I have learnt and applying it to actual situations in the workplace and obtaining feedback on what I did well and what I should look to improve on next time. This would provide me with the assurance that, not only do the techniques work, but also that I am progressing in the right direction. It would be an invaluable confidence builder both in my abilities and that the learning plan is delivering the desired results.

Monitor and Evaluate Self-development

One method to monitor and evaluate self-development

I would monitor and review my learning using a learning log. This could be used to plan learning activities as milestones on the way to achieving the completed development activity and as a reference to check that milestones are being completed on time (through one-to-ones with the line manager).

The log allows the user to focus in on the particular learning areas which are important to him, and to visualise the progress being made. For me, this would apply to areas such as assertiveness, communication skills and Environmental knowledge, for example. The log will allow others, such as team members and the line manager to understand what it is that an individual is trying to achieve and provide assistance and feedback where it is required.

In addition, the learning log is a good tool for recording feedback, enabling the noting down of what went well and what could be improved with each learning activity as well as how the approach can be changed next time. Eventually, it should indicate for me, whether “soft skills” are still a learning area of me or whether I have shown, through practical demonstration, that I have mastered them.

An example of a real learning log (extract) is attached as Appendix B to this assignment.

For feedback to be effective, the Action Impact Do/Develop/Different model should be applied That is, the person giving the feedback should provide examples of what was done, its impact on the situation, and what should be done differently next time. This would allow the recipient to consider a different approach and modify his behaviour accordingly This is particular relevant to the skills I am trying to develop.

Appendix A – Personal SWOT Analysis


I have a strong compulsive need to do things quickly especially when my “to do” list is long. Sometimes this has compromised my decision making ability.

My need to keep the customer happy can sometimes lead to me acquiescing to his needs rather than defending my own position.

I have a tendency to over-analyse what has happened in certain situations (even after I have prepared really well for them) when events have moved on and I can no longer do anything about them.

I get a little nervous about presenting to members of the team and to customers. This can mean that these types of Presentation do not engage the audience as much as I’d like.


I have good analytical skills. I enjoy looking through data to determine conclusions and action planning to improve the current situation.

I am very conscientious and deliver all work to the very best of my ability.

I pride myself in organising my work so that it is always delivered on time. I go out of my way to satisfy or delight the customer.

I am completely committed to the success of the team that I work for and creating a good impression of what we do to our customers/stakeholders.

I have worked in Assurance/Quality related roles for over 20 years and have experience in most aspects of these functions.

My job means a lot to me, I take it very seriously.


Potential future reorganisations meaning redundancy. Assurance becomes no longer a priority for the company.

Perceptions and criticisms by customers and own team.

2012 move to Milton Keynes and the feasibility of commuting there on a daily basis.

My current need for a lot of support from my line manager could be perceived that I no longer feel comfortable in taking decisions without someone’s help.


We are currently developing a customer feedback questionnaire which we will get our main stakeholders to complete. The output from this should help us to determine the areas we need to improve on going forward

We have a lessons-learnt process and are always looking to improve the auditing process.

That I take the knowledge I’ve accumulated from the Leading and Managing Teams course and consistently look back on it and apply it to my day job.

That I continue to work with my main customers to build a reputation with them so we are clear about what we expect from each other and that this leads to a positive working relationship which delivers results.

Appendix B – Learning Log (extract only)

Date From

Date to


What went well?

What didn’t go well?

What you will do differently next time

Nov. 09

Dec. 09

E-Learning Course – “Assertiveness”

The course was completed and all of the intermediate assessments passed

There was no interaction element to the course – how do you know it works in practice?

This needs to be incorporated into 1-2-1 meetings – to get feedback from line-management on how I am progressing/if this is still a development area for me.



Opening Meeting – CrossRail audit

All of the points on the agenda were covered

Organisation was poor – jumped from one topic to the next and then back again in a haphazard fashion

Improve preparation – plan out exactly which points to cover and at which times



Closing Meeting – CrossRail audit

Far more relaxed, bought the correct key people to the meeting – deflected difficult questions to them at the right time

Nothing to report – do it the same next time.

Carry this lesson forward for the 2010-11 National Core Audit Plan (NCAP).



One-day training session – “Environmental Management on Projects”

A good internal training session about how to apply the requirements of the Network Rail Environmental Management Handbook (Guide to Railway Projects Delivery Manual 04) on Projects

Additional time to built into the course to go through some of the worked-examples in further detail.

This knowledge needs to be applied in future as part of the 2010-11 NCAP audit of Environmental Management. Opportunity to be sought to take part in this section of the audit.


Preferred Learning Style/s


What do I want or need to develop?

What actions / development will I do to achieve this?

How will success be determined?

Target dates for review and completion

1.My “soft” skills; e.g. Assertiveness, Listening, Coaching abilities

E-Learning. Mentoring from my Line Manager. Experiences in my role.

1-2-1s; performance review meetings; improved confidence

April 2010 (end of year review)

2. Understand Environmental Management on Network Rail Projects

Network Rail course – “Environmental Management within Network Rail” – assisting National Core Audit Programme with Environmental auditing aspects.

I will be able to carry out effective Environmental Audits of Network Rail Programme/Projects as determined both by Environmental Specialists on the Programmes and by the Investment Project Environment Manager.

October 2010 and April 2011


In USA the Institute of medicine reported that 44,000 to 98,000 deaths caused by medical errors yearly.7,000 of them due to medication errors. In addition, Johnson and Bootman calculated 116 million visits to doctors, 17 million visit to Emergency Department, 8 million hospital admissions and 3 million long-term care admission per year due to medication errors (Kwabena 2004).

We are going to discuss the most common types of errors, the causes of errors and some of the strategies to reduce and prevent medication errors.

Types of Medication Errors

Three people involve in medicine, the doctor who will order the medicine, the pharmacist who will supply the medicine and the nurse who will give the medicine. Any mistakes done by any one of these three people will result in medication error. Thus, there are three main types of medication errors, the prescribing errors, the dispensing errors and the administering errors.

Prescribing errors:

The doctors are responsible for prescribing the medicines for the patients. There are three types of prescribing error: using wrong drug name, wrong dose and wrong dosage frequency.

To start with, it is very common to use wrong drug name as there are new medicines entering the market every year. There are more than 17,000 trade and generic name for pharmaceuticals marketed in North America (Kwabena, 2004).In addition, the medicine dose and frequency vary from patent to patent for example, children, elderly and renal patents requires special attention in writing the dose. Furthermore, some medicines require special dose tapering before they can be completely stopped. Moreover, calculating the dose need special mathematical technique where doctors may not have the time and experience to do.

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In interviews done in Australia with 15 doctors who had contributed to a significant medication errors, they admitted that the prescribing errors was due to slips in attention or lapses due to memory failures and 8 errors was knowledge- based mistakes. These mistakes happen when the doctors are busy, tired or working with unfamiliar patients or patients who have complex condition. The Knowledge-based mistakes were mainly due to the difficulty to access the drug information, guidelines or protocols. In some cases, junior doctors didn’t ask help as they don’t want to disturb a busy colleague or they were having low expectation to get help. This indicates serious communication problems in the team. In addition, two doctors state that they increase sedation for older patients because they felt pressured by nurses to do that. Furthermore, 10 of the 15 doctors did not know that, they caused a medication error until the research team approached then as the errors happened with unfamiliar patients (Nichols P, 2008).

Dispensing Errors:

Dispensing medicine is the pharmacist responsibility. Pharmacists are also responsible for integrating and evaluating the dose, the route, the frequency and the treatment duration.

In addition, the pharmacist should play a major role in answering all the medications enquires by the doctors and the nurses.

In UK and USA studies showed 10% incidence due to dispensing errors even in advanced medication distribution systems. In a study done in a public paediatric hospital in Brazil in 2005-2006, a total rate of more than 10% dispensing errors was found. Errors were classified as content errors, labelling errors and documentation errors (Costa LA, 2008).

The most common content errors were the “missing doses” where medicine was supply in smaller quantity than what was prescribed by the doctor. On the other hand the “other labelling errors” which include the illegible name or number were the most common labelling errors. The documentation errors represent only 1.7% of the total errors, 40% of these errors were absent or incorrect documentation of controlled drugs (Costa LA, 2008).

Another study showed that the dispensing errors were due to attention slips, memory lapses and knowledge-based errors. Like the doctors and the nurses, the pharmacist give reasons of being stressed, tired and busy in doing multiple tasks in the same time (Nichols P, 2008).

Administering Errors:

Administering medications is a nurse’s responsibility, thus; administering errors are nurse’s mistakes. It is fundamental for a nurse to know the medication and all the aspect related to the medication such as, the action, side effects preparation and there inter action with other medicine.

A study was done in two elderly long stay wards in UK psychiatric hospital, by using direct observation, chart review and the incidents reports. A head pharmacist was observing the routine and the PRN (as required) medication administration at each daily routine medication round for over two weeks, than the pharmacist was checking the medication chart to asses if any error has been occurred during the administration time. Another pharmacist was checking the chart and recording the medication errors which were recorded in the chart. This pharmacist did not know the result of the errors recorded by the first pharmacist. After that the incident report was checked to record the medication errors which were reported

during that period. The data was analysed after the observational period. Administering errors were very common, occurring in one of four doses. The most common errors detected

in this study were crushing tablets or opening capsules without the prescriber permission, omission of the dose without a valid clinical reason, failing to sing the medication chart and giving wrong medicines quantity. Moreover, the observational study detected two and a half times the numbers of error than the review of the medication chart. Furthermore, none of the detected errors were reported in the incident reporting system (Haw, 2007).

Another study was done in a University hospital in Sao Paulo state, Brazil. In this study, the nurses supervisors were asked to write down all the enquiries which were asked to them by the nurses during the study period and their answers to clarify the doubt, than they were asked to write the sources of their information. By analysing the data collected in this study, it was found that; the most common questions were about the medication dilution (40.4%), 15.7% doubts were about administering technique and 11% doubts about the drug interaction. Moreover the nurse supervisors who are considered as expert and knowledgeable professionals give 35.5% incorrect or partially correct answers. These answers may have caused adverse reaction to the patient. Furthermore, the nurse supervisors’ sources of answers were from their own knowledge, literature and colleagues from other areas. Only 7.5% answers were obtained from pharmacists who suppose to be the first source of information, this may be either because of difficulty to reach them as they are far away from the clinical

practice or because the nurses did not consider them as the best source of information about medicine (da Silva DO,2007).

Patient role in identifying the errors:

Patients are the best observer of their care in the hospitals. Can the patients and their families identify the problems, the injuries or the errors affecting their care in the hospitals? A study was done in a medicine unit of Boston teaching hospital in USA to answer this question. 228 inpatients were interviewed during their hospitalization and than ten days after their discharge. 62 patients reported that they have incidents or near misses.47 of the incidents reported were medication related problems. Half of the incidents were not recorded in the medical record and none were reported in the incident reporting system (Weingart SN, 2005).

Strategies to reduce the medication errors:

Hospitals and staffs (doctors, pharmacist and nurses) are responsible for patient safety during prescribing, dispensing and administering medication.

Hospitals are responsible for providing safe working roles and environment. First of all hospitals should restructure their systems to improve the human recourses by increasing the number of employ and reducing the shortage of staffs. On the other hand the working hours should be reduced, the nurse to patient ratio should be improved and a 24hour clinical pharmacist should be present. Than hospitals should improve the human resources level by On the other hand, staffs have the major role in reducing the incident. Following are some steps to reduce the medication errors: providing continues training programs and promoting recycling. The hospitals should also provide a clear dilution protocol, up dated literature and a prescribing guideline. Another thing hospitals should do is providing an easy access to internet. Hospitals should also provide an electronic prescribing system to reduce the incidents occurring due to difficult handwriting and should consider using the unit dose dispensing system. Finally, the incidents reporting system should be improved in order to encourage staffs to report the incidents.

Use a personal formulary with the frequently used medicine and keep it up to date.

Use a digital appliance with internet service if it is possible.

Be familiar with the medication, their actions, side effects and inter action with other medication.

Keep yourself updated by attending courses and workshops.

Follow the five rights (right patient, right drug, right dose, right route and right time) and always check and double check before writing, supplying and giving the medicine.

Doctors and nurses should clearly state the patients full name and his number before writing or giving the medicine.

Doctors should write the purpose of the medicine in the medication chart (with maintaining patient confidentiality).

Doctors should prescribe medicine only when needed, they should not prescribe medicine only upon patient request.

Take the allergy history of the drugs from the patient or his family.

Take the history of any herbal therapy used by the patient and be aware of the most common herbal drug and their actions and side effects.

Repeat the verbal order and be aware of the “sound alike” drugs especially when using the phone.

Ask the pharmacist help whenever needed as they are the best source of information in medication.

Take prober history when dealing with unfamiliar patients.

Be organized and try not to involve in many tasks at the same time.

In case of any doubt take experts opinion before dealing with the medication.

When dealing with any new or unfamiliar medicine read about it first.

When dealing with chronic patient asked about all his medicine and if possible ask him to bring all the medicine with him.

Good communication between the health team should be maintain.

Take extra percussion when dealing with special population such as children, elderly and renal patient.

Involve the patient and his family in his care and explain to him the action and side effects of his medication.


Medication errors are one of the most serious aspects interfere the patient’s safety in the hospitals. By following the prevention Strategies, the doctors, the pharmacist and the nurses can provide safe medication administration to the patient. Hospitals on the other hand, are responsible for providing safe environment for the staffs to insure safe medication administration. Finally, the incident reporting system should be improved. It is possible that the fear or the lack of awareness prevents staffs from reporting the incidence. Educational program should provided to encourage the staffs to report the errors before the adverse reaction can occur.


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