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Evidence-Based Project on Medication Errors in Hospital Settings

Mr. Junaid Zia(76), Mr. Ijaz Ahmad, Mr. Mian Usman, Mr. Suleman Khan &Ms.

Musarat Nawaz

Institute of Nursing Sciences, Sarhad University of Information and Technology

Peshawar

Critical Care Nursing

Assistant Professor Mr. Khalil Khan

Co Faculty Mr. Gulshan Iqbal

February26, 2025
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Introduction

Evidence-Based Practice (EBP) integrates the best available research evidence with clinical

expertise and patient preferences to improve healthcare outcomes (Chesne, 2018). Medication

errors are a major concern in hospital settings, contributing to patient harm, increased

healthcare costs, and extended hospital stays. These errors can occur at various stages,

including prescribing, dispensing, administration, and monitoring (Tabatabaee et al., 2022).

The goal of this project is to assess the effectiveness of evidence-based interventions in

reducing medication errors and improving patient safety in hospital settings.

Prioritization of the problem

During clinical practice, several nursing challenges related to medication safety were

identified. The following key concerns were prioritized:

 How can medication errors be effectively reduced in hospital settings?

 What are the best available interventions for improving medication safety?

 How can standardized training improve nurses' adherence to medication

administration protocols?

 What role do technology and automation play in reducing medication errors?

Through structured discussions and voting with senior nursing staff, the team decided to

investigate “The Effectiveness of Evidence-Based Interventions in Reducing Medication

Errors in Hospital Settings.”

Problem statement

Medication errors are a leading cause of adverse drug events (ADEs) in hospitals. They

contribute to increased morbidity and mortality, prolonged hospital stays, and a decline in

patient trust in healthcare systems. Despite advancements in medication safety protocols,

errors continue to occur due to factors such as heavy workloads, inadequate training, and

communication breakdowns (Bates et al., 2020).

Justification of the problem

Medication errors are preventable and should be addressed through evidence-based

interventions. According to the World Health Organization (WHO, 2017), medication errors

account for nearly 50% of all preventable patient harm in healthcare. Studies suggest that

electronic prescribing, barcode medication administration (BCMA), medication

reconciliation, and staff training can significantly reduce error rates (Alqenae et al., 2020). By

implementing these strategies, hospitals can enhance medication safety and improve patient

outcomes.

Current practice

During our clinical observations, we found inconsistent adherence to medication safety

protocols. A survey was conducted to assess the current knowledge and compliance of

healthcare providers regarding medication safety measures. The questionnaire included the

following questions:

Knowledge & Compliance with Medication Safety

1. Do you follow a double-check system before administering medications? (Always,

Often, Sometimes, Rarely/Never)

2. How often do you use barcode scanning before medication administration? (Every

time, Occasionally, Rarely, Never)

3. Do you perform medication reconciliation during patient transitions? (Yes, No, Not

Sure)

4. Have you observed a reduction in medication errors with electronic prescribing? (Yes,

No, Not Sure)

5. What are the major barriers to medication safety in your hospital? (Lack of training,

High workload, Poor communication, No major barriers)

Picot Questions

P (Population): Hospitalized patients receiving medications.

I (Intervention): Implementation of electronic prescribing, BCMA, and standardized

medication reconciliation.

C (Comparison): Traditional medication administration methods without technology.

O (Outcome): Reduction in medication error rates and improved patient safety.

T (Time): Over six months.

This study aims to determine the effectiveness of technology and staff training in reducing

medication errors and improving overall patient safety.

Project Plan

This evidence-based project aims to implement and evaluate the following interventions:

1. Electronic Prescribing Systems – Reduces prescription errors by eliminating manual

handwriting and incorporating automated drug interaction alerts.

2. Barcode Medication Administration (BCMA) – Ensures accurate medication

administration by scanning barcodes on medications and patient ID bands.

3. Standardized Medication Reconciliation – Improves accuracy during patient

transitions between healthcare settings.

4. Nurse Training Programs – Enhances knowledge of safe medication practices and

error prevention strategies.

5. Error Reporting Systems – Encourages a culture of transparency and accountability in

medication error reporting.

Literature review

Medication errors have been widely studied in healthcare literature, emphasizing their causes,

consequences, and prevention strategies. Research by Bates et al. (2020) highlights that

approximately 5% of hospital admissions experience some form of medication error, leading

to increased morbidity and mortality. Alqenae et al. (2020) conducted a systematic review

and found that medication errors are prevalent across various healthcare settings, particularly

during patient transitions from hospital to community care. These errors often result from

poor communication, incorrect dosages, and lack of adherence to protocols.

Technological interventions, such as electronic prescribing and barcode medication

administration (BCMA), have been shown to reduce medication errors significantly (Tariq &

Scherbak, 2019). A study by the World Health Organization (2017) found that implementing

these strategies led to a 50% reduction in medication-related harm globally. Furthermore,

Tabatabaee et al. (2022) emphasized that night shifts and high workloads are major

contributors to medication errors, suggesting that proper staffing and workload management

can improve medication safety.

Nursing education and training also play a crucial role in reducing medication errors. Studies

indicate that simulation-based training and continuous professional development programs

enhance nurses' ability to administer medications safely (Institute for Safe Medication
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Practices, 2021). These findings reinforce the need for hospitals to implement structured

training programs and adopt technological interventions to enhance medication safety.

Methodology

Study Design and Setting

This study will be conducted in a private teaching hospitals in peshawar, focusing on

inpatient wards where medication errors are most likely to occur. A quantitative approach

will be used, incorporating both observational and survey-based data collection methods.

Population and Sampling

The study population consists of registered nurses working in the hospital. A stratified

random sampling method will be used to select participants from different departments to

ensure a representative sample.

Data Collection Methods

Data will be collected through the following means:

 Medication Error Reports: A retrospective review of hospital records to assess the

frequency and nature of medication errors.

 Surveys and Questionnaires: Structured questionnaires will be distributed to

healthcare professionals to evaluate their knowledge, perceptions, and adherence to

medication safety protocols.

 Direct Observations: Medication administration practices will be observed to

identify deviations from standard protocols.

Data analysis

Statistical analysis will be performed using SPSS software. Descriptive statistics will

summarize medication error trends, while inferential statistics (e.g., chi-square tests, t-

tests) will be used to evaluate the effectiveness of interventions.

Implementations

The implementation phase will involve collaboration with hospital administrators,

pharmacists, and nursing staff to integrate these interventions into daily practice. Training

sessions will be conducted to familiarize healthcare professionals with new protocols. The

effectiveness of these interventions will be measured by comparing medication error rates

before and after implementation (Institute for Safe Medication Practices, 2021).

Expected outcomes

By implementing these evidence-based interventions, this project aims to achieve:

 A significant reduction in medication errors.

 Improved patient safety and healthcare quality.

 Increased adherence to medication safety protocols.

 Strengthened reporting mechanisms for continuous improvement.

Conclusions

Medication errors pose a serious threat to patient safety, but evidence-based strategies can

mitigate these risks. By integrating technology, standardized protocols, and staff education,

hospitals can foster a culture of safety and accountability. Continuous monitoring and

adaptation of best practices will be essential in sustaining improvements in medication safety.

References

 Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and nature of

medication errors and medication-related harm following discharge from hospital to

community settings: A systematic review. Drug Safety, 43(6), 517–537.

https://doi.org/10.1007/s40264-020-00912-9

 Bates, D. W., Vanderveen, T., & Seger, D. (2020). Medication safety and hospital

safety programs. New England Journal of Medicine, 382(24), 2294–2301.

https://doi.org/10.1056/NEJMra1908685

 Institute for Safe Medication Practices. (2021). Best practices for medication safety in

hospitals. Retrieved from https://www.ismp.org

 Tabatabaee, S. S., Ghavami, V., Javan-Noughabi, J., & Kakemam, E. (2022).

Occurrence and types of medication error and its associated factors in a reference

teaching hospital in northeastern Iran: A retrospective study of medical records. BMC

Health Services Research, 22, 1420. https://doi.org/10.1186/s12913-022-08864-9

 Tariq, R. A., & Scherbak, Y. (2019). Medication errors: Causes and prevention.

StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/

 World Health Organization (WHO). (2017). Medication without harm – WHO global

patient safety challenge. Retrieved from

https://www.who.int/patientsafety/medication-safety/en/
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