Medication Errors: Resources for Practice

Abstract

The process of giving medication in an acute care hospital is an example of chaos principles. Each medication order, dispensing, administration and monitoring, and evaluation is unique. Each patient situation and concurrent medical problems is unique. Each person in the process of dispensing, administering, monitoring, and evaluation is unique. This sets up thousands of variables in interaction with medication administration. Because these variables are highly dependent on communication and human behavior, the outcome is that patient deaths occur. These problems were first highlighted by Kohn, Corrigan, and Donaldson (1999) in a report published in the Institute of Medicine’s (IOM). The challenges of making medication administration safer are even more acute in the rural hospital environment because resources are sparse.