Identify three factors that leads to errors in documentation related to medication administration. Please include References

Medical documentation is vital in assessment, planning, intervention, and evaluation of the patient care and administration of medication and therefore if done incorrectly it could lead to major harm to the patient. Here are three factors that often lead to errors in this area:

 1. Incomplete or Inaccurate Information

 Description: Documentation inaccuracies are usually experienced when the information that has been documented is either partial or wrong. These may comprise of what dosage of the given drug, when it is supposed to be administered, or the patients’ response to the medication.

 Impact: Lack of documentation creates confusion on the side of the care giver as to when the medication was given, whether it has been already given, whether a certain medication was given at all and when it was given and even the dosage that was administered.

 Reference:

 Kohn, L. T. , Corrigan, J. M. , & Donaldson, M. S. (2000). Crosstrial analyses of the to err is human study. Archives of Internal Medicine, 160, 1449-1459 To Err Is Human: Creating a Healthier Health System. National Academy Press. This paper explains the role of poor and poor documentation processes as causes of medication errors and recommend on how the gaps can be closed.

 2. Pervasive Absence of Standard Operating Procedures, and Flawed Protocols

 Description: Lack of conformity to the set documentation procedures and standards contribute to errors. Cohort members reported variation in written formats or electronic systems for documentation of medication administration among various nurses or other staff.

 Impact: Failure in the standardization can results to misunderstandings, complications and mistakes in regards to medication. The protocols of documentation are strictly followed to maintain uniformity and quality of the work done.

 Reference:

 ISMP or Institute for Safe Medication Practices. (2016). Safe and Unsafe Forms of Electronic Communication of Medication Information:Adopted by the International Society of Managed Pharmacy. ISMP. The guidelines also touch on the issue of documentation systems so as to minimize inconsistency and improve on the level of flow of information.

 3. Insufficient practice and problems regarding the applying of the framework

 Description: These occur due to poor teaching of the providers on the right methods of documentation or challenges in the implementation of EHRs. For instance, users can enter wrong information into an EHR or might not be conversant with the documentation system used.

 Impact: Lack of training, misimplementation, and lack of technology can result in wrong documentation that may result in giving wrong medication and harm patient safety.

 Reference:

 Bates, D. W. , Gawande, A. A. (2003). Reducing Risk with information Technology. NEJM, 348(25), June 26, 2003, 2526-2534. Due to advanced continually improving information technology, training and system design arose as critical success factors in elimination of documentation errors.

 Summary

 Potential errors in medication administration documentation include: inadequate information, no uniformity in the process and compliance to protocols, and insufficient staff training or technologic problems. These reasons need to be managed better through more effective utilisation of better practice, protocols, and training of the health personnel to make medication documentation a more reliable source for patient safety.

 References:

 Kohn, L. T. , Corrigan, J. M. , & Donaldson, M. S. to present for the committee on quality of health care in America ISBN 0-87553-144-X. To Err Is Human: Health System = A Safer Health System. National Academy Press.

 ISMP, Institute for Safe Medication Practice. (2016). In an effort to develop a systematic framework for the analysis of risks related to safe ISMP guidelines for the electronic communication of medication information have been established. ISMP.

 Bates, David W, and Atul A. Gawande. 2003. Safety of patients has been considered to have benefited from information technology through the following ways; Circulation The New England Journal of Medicine 348. 25 2526-2534