A systematic study of medication errors and their dynamics in hospital medication service processes

Abstract

[ACCESS RESTRICTED TO THE UNIVERSITY OF MISSOURI AT AUTHOR'S REQUEST.] Medication errors are serious threats to patient safety in acute care settings. In past studies, medication errors have not been studied from a system perspective. In this dissertation, a systematic medication error recording method was developed to record medication error reports from a voluntary reporting system. After data validation, the recorded medication error data were studied in both static and dynamic manners. The past medication error studies and the results of data analysis/data mining conducted in this dissertation provided a static view of medication errors and their contributing factors; meanwhile they were used as input information for a simulation model. By combining simulation modeling and fractional factorial analysis, the dynamics between medication errors, and other system factors, such as work demand, staffing, interruption, and technology, were studied. The result from this dissertation suggests that there are more factors contributing to medication errors than system efficiency level. There are no clear trade-offs between patient safety and system efficiency. Besides, the impact of technology is not always positive or negative. The key is how to plan the implementation of new technology to increase the adaptability of staff members. This study provides an all-around view of medication error and its dynamics. Having a systematic understanding of those significant factors, which contribute to medication errors, can improve patient safety in medication services in the future.