Fault tree analysis of commonly occurring medication errors and methods to reduce them

Abstract

Medication errors occur in health care settings and they continue to Pose significant challenges to hospital administrators, Physicians, Pharmacists and nurses. These medication errors may occur due to a lack of knowledge, substandard performance, or other defects in the system and they do lead to management burden and possible loss of confidence in the hospital by the attending physicians and the patients. This study investigated various published research on medication errors and conducted an in-depth analysis of over two hundred actual medication error incidents. These errors were then classified according to type, in an attempt at deriving a generalized fault tree for the medication delivery system that contributed to errors. This generalized fault tree diagr-am has helped identify the blocks that hinder system safety, and therefore, safe medication administration. This has helped m the formulation of a set of remedial steps that could be undertaken in order to prevent medication errors. A conceptual model of a computer system has also been developed, which has incorporated the remedial steps developed by this study.