by Paul Lines

Created on: July 04, 2007

The incidences of medication errors being reported over the past few years have increased dramatically. In addition to damaging hospital reputations and destroying the trust and confidence that should exist between the medical profession and the community, these errors are actually costing patient's lives and are therefore unacceptable. These errors appear to be happening for a number of reasons, and with many different types of medication delivery. Amongst some of the reasons given for medication errors are the following: -

1. Misunderstanding of the instructions of doctors and consultants. This can be due to bad handwriting or lack of understanding of the instructions given.

2. Medication nurse being interrupted during her rounds. Especially where medicines have to be measured, this can lead to incorrect doses being given.

3. Patients not being supervised in medicine taking. For example the medicine is left on their locker for them to take in their own time.

4. No system that allows for a double check on the medicine allocation process. Due to pressure of work and shortage of staff the ultimate responsibility for accuracy of medicine dispensing is the sole responsibility of one person in many cases.
These errors can occur whether the medicine is delivered to the patient as part of the ward round, give by an intravenous process or left for the patient to take without supervision.

In reality, there is no method to by which medication delivery to the patient absolutely error three, but there has to be attempts made to dramatically reduces the numbers of these areas that are occurring. In my view there are four ways that the current system can be improved.

a). By increasing the level of training and communication between the nursing, doctors and surgical staff to endeavour to eliminate the levels of misunderstanding that occur in this area.

b) To aim to achieve a system where there is a double-check process of checking medicine distribution and measuring.

c) By instituting a rule of non-interruption of any staff member in charge of the medication distribution process in the wards.

d). By stopping the practice of allowing patients to have medicine left unsupervised on their lockers.

If these measures are introduced and the funds made available to implement them it is felt that the numbers of medication errors would fall dramatically.

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