Enhancing Patient Safety in Healthcare Settings: A Systematic Investigation Framework to Reduce Medication Errors

Abstract

Preventable medication errors affect more than 7 million patients each year and cost almost $21 billion annually across all healthcare settings. Medication administration errors (MAEs) are identified to be highly occurring and one of the most severe among other categories of medication errors.

Despite some developed studies on analyzing medication errors, there is a need for the development of more robust, systematic methodologies to investigate their contributing causes and provide preventive measures to avoid their recurrence. This study proposes a systematic investigation framework, by adopting the AcciMap methodology originally developed by Rasmussen in 1997, to analyze contributing causes of MAEs and provides context-specific recommendations to reduce the instances of those errors.

The AcciMap methodology is a hierarchical, multi-layered framework with each layer representing a main group of involved players. The layers of the AcciMap framework in this study, from top to bottom, are: Government and Regulatory Bodies; Hospital; Management; Staff (e.g. physicians and nurses administering medications); and Work Processes, Events, and Conditions. It is noteworthy that not only does the AcciMap capture different socio-technical factors that contributed to MAEs across its layers, but also it depicts the interactions of those layers and their involved players.

The analysis of our developed AcciMap framework shows that both internal (to an organization) and external factors contributed to MAEs. Furthermore, organizational factors, among internal factors, have been identified as the root cause of questionable decisions made by staff and management. Factors such as economic pressure, inadequate training infrastructure, and ineffective communication were among influential organizational factors contributed to MAEs.