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Berit Anderson

Jun 23, 2021

Patient Safety in Healthcare - Minimising Medication Mix-ups


Last month, there was a massive mix-up in six major South Australian hospitals when an unknown number of patients were accidentally given up to ten times the recommended dose of Covid vaccine. The South Australian Health Chief blamed the bungle on a glitch that entered their prescribing software during routine upgrades. The Australian Nursing and Midwifery Federation state secretary agreed, adding that nurses cannot be expected to double- and triple-check every single dose against a manual or with a doctor because of the associated time and workload increase. Whatever the reasons for the medication mix-up were, the obvious fact remains that patients expected to receive accurate, trustworthy care at their local healthcare facility and did not get it.

Unfortunately, this is not a one-off incident. A study conducted across 36 health institutions in the US found that medication errors occurred nearly once in every five doses. The most common medication errors were –

  • the medication given at the wrong time,
  • a dose was skipped,
  • the wrong dosage was given,
  • or the wrong medication was administered.[1]

Current available statistics on the frequency of medication errors range widely from 32.1%–94%,[2] and the World Health Organisation (WHO) estimates that these errors cost healthcare organisations US$42 billion globally.[3] In fact, medication-related harm is such a pervasive issue in modern medicine that WHO selected it as the focus of the third global patient safety challenge in 2017, with a goal of reducing medication-related incidents of harm 50% by 2022. It is unclear how far down the global rates have dropped overall, but incidents like the Australian vaccine overdose are still making headlines so we know they are still occurring. So, what can health care providers do to better combat the persistent problem of medication mishandling?

Turning to Tech

Many health organisations have turned to various forms of new technology to try and remove some of the margin for human error from the process of medicinal prescription and administration. These solutions include things like electronic patient records, bar-coded medication administration, and prescribing software.[4] However, as clearly demonstrated with the Australian situation above, these technological solutions are not infallible – user error can still creep in, as can unforeseen glitches and other unexpected challenges.


This is a sticky situation with many complicating factors. Healthcare institutions invest in new medical technologies and systems with the assumption that they will improve quality of care and patient safety while gaining positive return on investment (ROI) by streamlining workflow and reducing workload on staff.[5] Health practitioners should  be able to assume some level of reliability in the systems and technologies they work with daily, or else these technologies are not reducing workload, they are adding to it. Health workers must already constantly balance challenging schedules and stressful working conditions while providing high-quality care to many different patients. They don’t need to add second-guessing technology to their too-long list of concerns. And patients need to have confidence that they will receive the correct prescription and dosage when getting medical care at a health institution. How, then, can healthcare providers offer the highest quality care to patients while maintaining reasonable workloads for staff, utilising the latest technology to its fullest potential, and catching mistakes before they cause serious harm? One of the ways to help do this is to incorporate online training into your staff development portfolio.


Online Training: A Proven Success

Evidence supporting the efficacy of online training in the medical industry is growing. Medical students who completed an e-learning course on patient safety as part of a controlled study in Germany gained significant, long-term technical knowledge, scoring markedly higher than their study counterparts who did not take the course.[6] The UK’s National Health Service Diabetes division designed and implemented a ‘Safe Use of Insulin’ online training course for its health practitioners, which has since resulted in improved levels of staff confidence in prescribing, handling, and administering insulin. Improvements in individuals’ working practice were also noted.[7] Researchers in England designed a short e-learning course on paediatric prescribing for junior doctors, and found that participants who took the course significantly improved their prescribing skills and confidence, and, when tested again 3-months later, retained this knowledge.[8]



Patient Safety = Prime Importance

Luckily, there were no adverse effects for the patients in Australia who received the vaccine overdose. Not everyone is so fortunate – in the United States, for example, medical error is one of the most common causes of injury or death.[9] Healthcare institutions must balance an ever-evolving list of complicated and intertwining factors, from tight budgets and stakeholder expectations to staff retention/turnover and cutting-edge technology implementation. However, patient safety must remain at the forefront of these priorities or everything else will be moot. Investing in online training is a solid move that can help keep your patients safe and improve your staff’s accuracy and confidence in the clinic.

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[1] Barker, K.N., Flynn, E.A., Pepper, G.A., Bates, D.W., & Mikeal, R.L. (2002). Medication Errors Observed in 36 Health Care Facilities. Archives of Internal Medicine, Vol. 162(16): pp. 1897–1903. doi:10.1001/archinte.162.16.1897

[2] Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, Vol. 13 (100235). https://doi.org/10.1016/j.ijans.2020.100235

[3] World Health Organization. (2017). Patient Safety: Making health care safer. Geneva: WHO. Available online at: https://apps.who.int/iris/bitstream/handle/10665/255507/WHO-HIS-SDS-2017.11-eng.pdf

[4] Agrawal, A. (2009). Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology, Vol. 67(6), pp. 681–686. https://doi.org/10.1111/j.1365-2125.2009.03427

[5] Brown, B. and Falk, L.H. (2013). How to Drive ROI in Your Healthcare Improvement Projects. Health Catalyst. Available online at: https://www.healthcatalyst.com/how-to-drive-roi-in-your-healthcare-improvement-projects-html

[6] Gaupp, R., Dinius, J., Drazic, I., & Körner, M. (2019) Long-term effects of an e-learning course on patient safety: A controlled longitudinal study with medical students. PLOS ONE 14(1): e0210947. https://doi.org/10.1371/journal.pone.0210947

[7] Eyres, G., Richards, L., James, J., Morton, A. & Sweeney, G. (2012). The NHS Diabetes Safe Use of Insulin e-learning module: is it making a difference to health care professionals? Practical Diabetes, Vol. 29: pp. 312–314. https://doi.org/10.1002/pdi.1713

[8] Gordon, M., Chandratilake, M., & Baker, P. (2011). Improved junior paediatric prescribing skills after a short e-learning intervention: a randomised controlled trial. Archives of Disease in Childhood (96), pp. 1191–1194. http://dx.doi.org/10.1136/archdischild-2011-300577

[9] Rodziewicz, T.L., Houseman, B., & Hipskind, J.E. (2021). Medical Error Reduction and Prevention. [Updated 2021 Jan 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/


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