Name: Capella University
Dr. Lisa Newton
May 2023

Enhancing Quality and Safety

Globally, medication mistake errors are the main consideration in healthcare settings. At any stage of treatment, prescription and administration, these medication errors can occur which have adverse consequences on the patient’s health results. Across the US, medication mistakes are a major problem that kills one person and injures 1.5 million individuals yearly (Aseeri et al., 2020). Research studies have validated that medication mistakes rank third among the leading causes of death after cancer and cardiovascular diseases (Rasool et al., 2020).

Healthcare workers have a key responsibility for these medication mistakes. This issue is critical depending on various factors and making every stakeholder responsible. The multiple organizational factors might be poor communication, inadequate training, mistaken documentation, data gaps, and technological barriers. Whereas, patient parameters causing medication mistakes are insufficient health awareness, compliance and wrong self-prescriptions. There is a need for multi-aspect strategies for handling medication mistakes. This strategy will require strong communication and collaboration among patients, doctors, healthcare providers, nurses, administrators, and other related stakeholders. Moreover, for the enhancement of patient safety, sufficient training, assessment, and evaluation are important.

Scenario for Medication Errors

A 50-year-old man reported chest tightness, pain, and breath shortness due to which he was hospitalized. His medical history showed that he has hypertension and increased cholesterol. The preliminary identification revealed that he had a blocked heart artery which needed angioplasty. The angioplasty surgery was planned for the very next day. He was prescribed medicines for blood thinning and analgesics to control the present condition. That man was allergic to one of the medicines but this fact was missed out by the nurse who was checking his medical and medication history.

Consequently, the patient suffered from a severe allergic reaction which caused breathing discomfort and throat swelling. The healthcare staff right away handled the situation by giving the patient an antidote for the allergic response. The patient got stabilized and normal but there was a higher probability of complications due to medication mistakes. This careless and irresponsible event was reported to the organization’s administration. It immediately formed an investigation committee to find the root cause of medication mistakes and to avoid such events from occurring in the future.

Factors Leading to Patient Safety Risk

Medication mistakes put the patient at high safety risk and threaten his life. These errors can occur at any phase of the medication procedure such as diagnosis, prescription, transcription, purchasing, and administration (Tariq & Scherbak, 2023). Various factors that are linked with medication errors are insufficient health education, poor training, disproportionate staffing, extreme work burden, time constraints, non-compliance with the medical standards, poor communication among healthcare workers, departments, and patients, and inappropriate evaluation (Suzuki et al., 2022). These aspects can increase the probability of medication mistakes and can accelerate bad drug incidents, high healthcare expenditures, and decreased patient contentedness.

In this incident, the patient could have suffered severe implications due to a medication mistake which led to an adverse allergic reaction. If it is not dealt with immediately, this could increase the disease complications for the patient. The possible factors for this medication mistake are non-compliance with double-checking methodology, inadequate training, and poor communication. The patient’s medical and medication history was not read properly by the respective nurse which is an important stage in patient safety interventions. Moreover, the healthcare organization might not have an appropriate medication error prevention system i.e., barcodes and digital data entry.

Solutions Based on Evidence-based Best Practices

The main objective of healthcare workers is to give prime priority to patient safety. Medication mistakes can be decreased significantly by using evidence-based solutions and best medical practices. Electronic Medication Administration results (eMARs) are one of the potential solutions. It can reduce the probability of medication mistakes by ensuring instant access to updated patient’s medical history and decreasing the misinterpretation errors of manual prescriptions (Karnehed et al., 2021).

Another solution for reducing medication errors is medical reconciliation. In this procedure, the current medication prescription is reviewed with a recent medication regimen to determine any medication gap and seek another possible medication for reducing change of medication mistakes (Alrabadi et al., 2021). It can assist in avoiding bad allergic responses and enhance patient health results. Moreover, by encouraging patient engagement and education, medication mistakes and patient safety can be improved (Kim et al., 2020). This can be fulfilled by patient dashboards, medication training reservoirs, and strong communication between healthcare providers and patients. Reduced healthcare expenditures and enhanced patient safety can be ensured by implementing these evidence-based practices.

The Role of Nurses in Coordinate Care

For ensuring safe medication regulation, effective and coordinated patient’s care is a prime responsibility of the nurses (Mardani et al., 2020). By following medication reconciliation procedures, nurses can handle medication mistakes. This includes critically reviewing the medication prescription, and history and validating medication sequence with doctors to ensure the safe and correct medicine doses for patients.

Furthermore, nurses can play a role in education of patients and their families regarding safe medication, side effects, drug reactions, and medication orders. This will also prevent bad drug incidents and decrease healthcare expenditures of supplementary interventions and prolonged hospital stays (Budreviciute et al., 2020). For optimized patient’s care, nurses should coordinate with inter-professional teams including physicians, doctors, and pharmacists. They will establish medication regulation standards for encouraging medication guidelines compliance and guarantee the best patient care provision. Besides reducing healthcare expenses, these measures also assist in ensuring patient’s safety and improved health results.

Care Coordination and Stakeholders

To encourage patient safety and quality enhancements in medication regulation, strong collaboration among stakeholders is important. Nurses should collaborate with the inter-professional team comprising of pharmacists, doctors, and healthcare workers who are the main stakeholders. This collaboration will assist in developing evidence-based medication control guidelines, increase compliance with safe medication protocols and encourage the best patient care provision (Ravi et al., 2022).

Other than healthcare workers, patients are also key stakeholders in medication regulation (Cho et al., 2020). Nurses should train the patients and their families in medication administration such as side effects and drug interactions to avoid any bad drug incidents and immense healthcare expenditures. This training will assist patients and families in engaging in medication regulation and care advocacy.

Other main stakeholders are policymakers and hospital managers with whom nurses should collaborate and work on patient safety and medication mistakes (Lübbeke et al., 2019). Nurses can coordinate with policymakers and managers to establish and execute policy legislation and financing to encourage training and education on medication management.

At last, nurses themselves are key stakeholders in providing safety and quality improvements in medication management. Nurses should stay up to date on the latest skills, healthcare knowledge, evidence-based practices, and policy frameworks. High-quality care practices, elite patient’s safety, and enhancement in medication management in the healthcare system can be ensured by nurses’ training and education.


Nurses play a vital part in providing safety and quality improvements in medication management in collaboration with various healthcare stakeholders. This well-coordinated and collaborative strategy will reduce potential risks in patient safety, decrease healthcare expenditures, and enhance patient health results. Moreover, nurses should stay up to date about the latest healthcare skills, knowledge, pieces of training and education. It will enable them to ensure elite care quality and medication management enhancements across the entire healthcare setting.

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.

Aseeri, M., Banasser, G., Baduhduh, O., Baksh, S., & Ghalibi, N. (2020). Evaluation of Medication Error Incident Reports at a Tertiary Care Hospital. Pharmacy, 8(2), 69.

Budreviciute, A., Damiati, S., Sabir, D. K., Onder, K., Schuller-Goetzburg, P., Plakys, G., Katileviciute, A., Khoja, S., & Kodzius, R. (2020). Management and Prevention Strategies for Non-communicable Diseases (NCDs) and Their Risk Factors. Frontiers in Public Health, 8(574111).

Cho, I., Lee, M., & Kim, Y. (2020). What Are the Main Patient Safety Concerns of Healthcare stakeholders: a mixed-method Study of Web-based Text. International Journal of Medical Informatics, 140(1), 104162.

Karnehed, S., Erlandsson, L.-K., & Norell Pejner, M. (2021). Nurses’ perspectives on an electronic medication administration record in home healthcare: Qualitative interview study (Preprint). JMIR Nursing.

Kim, Y.-S., Kim, H. S., Kim, H. Ah., Chun, J., Kwak, M. J., Kim, M.-S., Hwang, J.-I., & Kim, H. (2020). Can patient and family education prevent medical errors? A descriptive study. BMC Health Services Research, 20(1).

Lübbeke, A., Carr, A. J., & Hoffmeyer, P. (2019). Registry stakeholders. EFORT Open Reviews, 4(6), 330–336.

Mardani, A., Griffiths, P., & Vaismoradi, M. (2020). The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review. Journal of Multidisciplinary Healthcare, 13(13), 1347–1361.

Rasool, M. F., Rehman, A. ur, Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Ahmad Hassali, M. A., & Hayat, K. (2020). Risk Factors Associated With Medication Errors Among Patients Suffering From Chronic Disorders. Frontiers in Public Health, 8(1).

Ravi, P., Pfaff, K., Ralph, J., Cruz, E., Bellaire, M., & Fontanin, G. (2022). Nurse-pharmacist collaborations for promoting medication safety among community-dwelling adults: A scoping review. International Journal of Nursing Studies Advances, 4, 100079.

Suzuki, R., Uchiya, T., Nakamura, A., Okubo, N., Sakai, T., Takahashi, M., Kaneko, M., Aiba, I., & Ohtsu, F. (2022). Analysis of factors contributing to medication errors during self-management of medication in the rehabilitation ward: a case-control study. BMC Health Services Research, 22, 292.

Tariq, R. A., & Scherbak, Y. (2023, February 26). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing.


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