Errors in prescribing or administering medications are serious problems and can endanger the lives of patients. "Medication errors" occur when a drug has been inappropriately prescribed, dispensed, or administered. The fact is, medication errors may occur in any health care setting.
The Texas Board of Nursing (BON) and the Texas State Board of Pharmacy issued a joint Position Statement addressing medication errors. The Boards issued the joint statement "for the purpose of increasing awareness of some of the factors which contribute to medication errors." Though Board Position Statements do not have the force of law, they are a means of providing direction for licensed professionals on issues of concern to the respective Boards, relevant to the protection of the public.
The joint Position Statement places a focus on review of systems, over a focus on individual competency in regard to addressing medication errors. A focus on systems is to help determine the root causes of medication errors and help guide the proper strategies to effectively reduce errors. Research suggests the majority of medical errors "do not result from individual recklessness," but rather from flaws in the way the health system is organized.
A comprehensive approach is necessary to reduce the occurrence of errors. The BON and the Board of Pharmacy agree that such an approach includes three major elements:
- The individual professional's knowledge of practice;
- Resources available to the professional; and
- Systems designs, problems, and failures.
Each of these three elements must be addressed in a comprehensive approach.
To reduce the probability of medication errors, licensed professionals should only accept patients and assignments "for which they have the appropriate education and which they can safely perform."
Learning about the resources available in any practice setting can help decrease the prevalence of medication errors. The joint Position Statement encourages teamwork and states that "Health care professionals must not be reluctant to seek out and utilize each other as resources." Further, the Boards' position is that "health care organization have the responsibility to develop completes and thorough orientation of all employees," to maintain adequate policies as guidelines for practices, and offer relevant opportunities for continuing staff development.
Finally, the third element focused on systems designs requires a review of existing systems for effectiveness and overall commitment to guaranteeing client safety. Technological advancements should be considered, and the system "should contain a comprehensive quality program for the purpose of detecting and preventing problems and failures." Finally, it is critical that a method for reporting errors within the system be available and understood by the staff.
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