Assignment on Medication Error

A medication error is an unintended mistake made in the use of a drug that can cause harm to the patient and that can occur for many reasons when prescribing, dispensing, storing, preparing or administering a medicine. Poor adherence to physician prescriptions is the main cause of ineffectiveness of drug therapies and is associated with an increase in health care interventions, morbidity and mortality, representing damage to both patients and the health system and society. (Kenji Fujita, 2018)
Main Issues Identified:
On analysis, one of the major issues, identified is that at the time of discharge there is no instruction related to the medicine is given to patient. One of the main issues associated with the medicine is the logistic problems as per in this case reconciliation of medicine at the point of transition if important. (Basger BJ, 2015) And there was no involvement of pharmacist in her care before they discharged her from the hospital. The pharmacist role is to ensure that they’re going through the discharge medication prescription to check for correct dosage, to provide medication information, evaluate medication, to improve medication adherence, medication management, assess health status.
Secondly, it is found that there is a lack of information listed on the discharge summary. Further there is no significant findings from the physician and the cardiologist and no treatment provided in the hospital. Also, the type of dressing was put on and for an ongoing dressing change
Thirdly there was communication barriers as the nurse won’t be able to understand what patient has said. Ineffective communication can also lead to medicine errors.

Also, there is incorrect medication dosage prescribed on gliclazide. And the incorrect information provided to the patient post procedure regarding ongoing wound care management and treatment

The other issues involved negligence of the nurse by not involving a pharmacist in her discharge process. And there are too many medications which has confused the patient and difficult solution provide blister pack with a clear instruction


Intervention for the Pharmacist
Pharmacists play a vital role in providing medication safety all across the continuum of care. But, it is noted that the complication of medicine prescribing as well as delivery methods could make it even more difficult/complex to prove the useful pharmacists impact on destructive effects at once, however, the involvement of pharmacist has been revealed to lessen errors, enhance prescribing practices, as well as, increase affected person monitoring across settings and in this situation, the affected person has no preliminary understanding of proper usage of the medicine which in-return provide complete negligence/carelessness from the side of the pharmacist.

  1. Recommendation
    While discharging the patients, the pharmacist should keep in mind the following main points:
    a) The pharmacist should well-informed the patient about their current condition and provide them “a through discharge medication list which shows the comprehensive medication information (general medication name, dose, dosage form, directions, PRN and regular medication, etc.), duration and indication of the new medication, an illustration of changes which might have been made to the usual medications, and proper details regarding medication management plan as well as medication management needs.
    b) Before discharging, the pharmacists should educate the careers and patients properly regarding appreciate usage and storage of the medications and potential risks and side effects of the medicine, and what to do in case of not taking the recommended dose properly on-time. Furthermore, it should be ensured that the patient has understood all the instructions and able to follow the medication instructions.
    c) The pharmacist can also arrange the medication trial which is considered as the best way to examine whether the patient can take independently all medications before discharging and can also use the pharmacy outreach service. Through this service, the nurse can visit the home of patients after their discharge to check their management of medication, provide education as well as facilitate continuity of care (Hanlin Li, 2016).

Intervention for improving the communication
In this case as the patient is not able to clearly communicate with the nurse which make the nurse difficult in understanding her condition. So, there should be some interpreter involved that helped her in explaining the present condition of patient. (Moore, 2004)
A poor or delayed communication between a patient and the pharmacists can cause a lot of problems due to a lack of continuity among the medicines at the time of discharge. It is also found from the study that almost 19% to 23% of discharge patients have an adverse experience after discharge and not proper communication regarding medication can make the treatment jeopardize as well as also enhanced the risk of re-admission to the hospital. Therefore, through this study, a few recommendations are provided to avoid miss-communication between patients and the nurse.
a) Patients require understanding and knowledge as well as support for motivation & for undergoing medicine therapy. For avoiding miscommunication physicians must adhered to teamwork & also promote effective communication among patients. They must be aware with situation (Manojlovich, 2017). In this case, on discharging many concerned health workers were involved such as nurse who discharged her, physician who prescribed the medicine and final workers. It is seen total lack of communication among the team. The patient must be informed correctly about its current condition, suggest some self-care strategies and proper schedule of the medication. Moreover, patient must be encouraged to follow-up care plan by describing the significance and fruitful results of the plans in terms of achieving the optimum level of health as well as decreasing the chance of readmission to a hospital. (Shitu, 2018)
b) If a patient is not in the condition to listen to all self-care strategies, then, there should be professional health care interpreters in order to ensure proper communication between the nurse and the patient. The interpreters will communicate the after discharge treatment plan to the patient accurately (smith, 2019).

Basger BJ, M. R. (2015). Development of an Aggregated System for Classifying Causes of Drug-Related Problems. . Ann Pharmacother .
Hanlin Li, P. W. (2016). Incorporating a Pharmacist Into the Discharge Process: A Unit-Based Transitions of Care Pilot. Hosp Pharm.
Kenji Fujita, R. J. (2018). Quality indicators for responsible use of medicines: a systematic review. BMJ Open.
Ludwik K. Branski, a. R. (2008). A porcine model of full-thickness burn, excision and skin autografting. Burns.
Manojlovich, M. D. (2017). Healthy work environments, nurse-physician communication, and patients’ outcomes.
Moore, P. M. (2004). Communication skills training for health care professionals working with cancer patients, their families and carers. Cochrane Database of Systematic Reviews,.
Ridiandries A, T. J. (2018). The Role of Chemokines in Wound Healing. Int J Mol Sci.
Shitu, Z. (2018). AVOIDING MEDICATION ERRORS THROUGH EFFECTIVE. Movement, Health & Exercise.
smith, s. (2019). Discharge planning: the need for effective communication. LIAISON NURSING.

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