Medical Errors and Patient Safety – Health System Example

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"Medical Errors and Patient Safety" is an exceptional example of a paper on the health system. Medical errors have been listed as a major cause of death in the United States. Moreover, reports show that it is also costly to minimize the occurrence of such errors (Berntsen, 2004). Some of the errors result due to insufficient drug information. Such an error may result in patients being administered with an overdose or the wrong dose. This is a major cause of death, especially among infants. Some of the major error documented has taken place from the prescribing phase to the drug administration phase (Smetzer, 1998).

However, some of these errors are linked between individuals involved in the accomplishment of the process. This paper will delve into patient safety. Insufficient drug information   Some of the incomplete drug information results from system failure (Smetzer, 1998). The problem of insufficient drug information results from the pharmacist. The pharmacists are unfamiliar with the treatment of certain diseases. For example, in Miguel's case, the pharmacist had limited knowledge about the rarely used, non-formulary drug (Smetzer, 1998). This led to the consultation of non-pediatric pharmacists to determine the infant dosage.

  This was disastrous as the pharmacist misread the drug in terms of units. Secondly, poor referencing further complicates the insufficient drug information. This caused the nurse in Miguel's case to administer medication I. V. instead of I. M (Smetzer, 1998). Therefore, there was no warning regarding the alternative use of drugs.   This makes the nurse assume the usage of drugs, and hence detrimental to the health of the patients. Moreover, in this case, the text had used ambiguous names when referring to various forms of penicillin (Smetzer, 1998).

In addition, the hospital fails to have clear guidelines on the prescriptive authority of non-physicians (Smetzer, 1998). The Language Barrier The language barrier is another form of system failure. This prevents the staff from discussing other options available for treatment. In Miguel's case, the neonatologist failed to be convinced that the parents understood the importance of follow-up (Smetzer, 1998). This prompted the neonatologist to treat the infant while in the hospital without first getting the lab report to ascertain this action. Precautions Various precautions can ensure that system failure is avoided.

Firstly, there needs to be medication error and patient safety measures (Berntsen, 2004). Secondly, there should be education sessions, including national conferences to reduce the effects of the language barrier. Moreover, there should be designing of computerized physician order entry system, and adoption of other forms of safety technologies (Berntsen, 2004). Moreover, there should be sharing of error preventive strategies among the hospitals. The legislation also needs to be passed that would prevent medical error data.   Additionally, there should be the development of a mandatory medical error database, and non-punitive measures should be put into place (Berntsen, 2004).

This precaution should emerge from the hospital administration. Influence These findings are important. They will influence my future practice as RN. Firstly, I will be able to reflect on patient safety while carrying out my duties. Moreover, I have realized that in the treatment of a patient making assumptions is not an option. Conclusion It is clear that various hospitals have made progress towards the treatment of patients in the United States. However, patient safety needs to be advanced as technological advancement continues to take place.

Lastly, the well-being of a patient is the responsibility of various stakeholders involved in the patient care.


Berntsen, K. (2004). “How Far Has Health Care come since "To Err Is Human"? Exploring the Use of Medical Error Data.” Journal of Nursing Care Quality, 19(1): 5-7.

Smetzer, JL. (1998). Lesson From Colorado: Beyond Blaming Individuals. Nursing Management, 29(6): 49-51.

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