Student Dissertation

Agency : Medication Safety, Medication Process, Quality Improvements, Automated Technologies

Recommendations : Systems and processes for prescribing, supplying and administering inpatient medications can have substantial impact on medication administration errors (MAEs). However, little is known about the medication systems and processes currently used in the hospital. This presents a challenge for developing interventions to increase medication safety. We therefore conducted an observational study of medication systems and processes in Delhi Heart & Lung Institute to address this knowledge gap. The research design was descriptive type in nature. The purpose of the study was to provide hospital with information on the extent to which medication errors can occur and the presence of factors that generally increase the chance of medication errors which ultimately compromises the patient safety. The data was collected by direct observation of the patient records, prescription, dispensing and during medication administration. Observation of the storage of the drug at bedside and in the nursing station was done. The study results were recorded in self developed excel sheet. We detected a total of 83 breaches in 176 opportunities for errors (47.2%). The most common types of error throughout the medication process were: missed dose, wrong time of drug administering, wrong dose and some miscellaneous causes. Other factors were also analyzed compromising the medication safety. There is a need for quality improvement, as almost 32.5% of all errors in doses and prescriptions in the medication process were caused by missing actions. We assume that the number of errors could be reduced by simple changes of existing procedures or by implementing automated technologies in the medication process.