Medical Errors at Mary Hill Hospital

The transition of patients from hospital to their home settings is considered to have a high risk of developing comorbid diseases and serve as a cause of death. Among the key reasons for the discharge errors, there are unclear instructions or a lack thereof, which leads to medication continuity mistakes and poses a threat to patients’ health outcomes. As stated by Ahmed et al., (2019), patients receiving hospital-based care are subjected to a minimum of one medical error daily. Discharge mistakes are regarded as one of the most widespread medical errors, and it usually occurs when the discharge team fails to communicate properly. Therefore, there is a need to change the current policies that are related to discharge, which would reduce threats to patient safety. In particular, hospital systems should be adjusted to promote trust and openness between the care team members so that they can share, translate, and clearly understand patient-related information.

Mary Hill Hospital

Problem Identification

Through the critical review of the Mary Hill Hospital data, it becomes evident that there are such systemic errors as a lack of procedures that manage dispensing medicines and diagnoses. As a result, the errors that are made by the care providers impact not only the physical health of patients but also their emotional and psychological well-being (Marvin et al., 2016). When patients and families sue hospitals for errors, it sets an additional financial burden. The disintegration of various hospital departments leads to misunderstanding and poses risks. Medical discharge errors in the hospital involve up to 70% of the hospital admissions for the last six months (Ahmed et al., 2019). Kushniruk and Borycki (2018) state that 28-40% of the medication is either replaced or discontinued during hospitalization, while less than 10% of older adult patients are being discharged under the same medication. The channels of communication among the team members are not established properly so that when a physician prescribes medication, a discharge nurse can be unaware of the latest updates. In others words, Mary Hill Hospital fails to ensure safeguarding policies to protect its patients.

Reducing Discharge Errors

The response of care providers to the problem of medical errors during the discharge can considered from the point of integrated ethics. The patient safety should be regarded as a top priority, which, in the given case, refers to changing the procedures of transferring patients from the hospital to home settings (Arries, 2014). The principles of beneficence and non-maleficence identify nursing profession as the active movement towards improving a patient’s quality of life. Accordingly, the best care practices, elaborate systems and informatics, as well as safety increasing procedures should be implemented. Every member of the interdisciplinary team should be explained that the process of discharge requires their attention and response to the emerging challenges (Arries, 2014). It is not sufficient to provide the list of prescriptions since a patient should be clearly instructed, and the care providers should be confident that his or her words were properly understood by the patient.

Speaking about other involved care providers, management technicians and pharmacists should be noted as the key persons who are expected to ensure the quality and safety of medication prescriptions. Reconciliation is critical to make sure that a certain patient would be given relevant drugs, which would minimize the occurrence of medical errors. In addition, training of the mentioned personnel is necessary to keep them competent and aware of evidence-based interventions that are being implemented by physicians and nurses. The operational level of efficiency can be measured based on their work indicators (McHaney et al., 2019). An electronic patient record (ePR) documentation system is another change, the use of which is significant to structure and organize information. Accurate records and timely transfer of data would serve as the basis for the discharge team to check medication and instructions and also discuss them with patients. As stated by Crisp (2016), the use of information systems improves the connection between the organization and care providers as it facilitated communication and promotes the creation of a culture of transparency.

Considering that there are many unintentional discrepancies, the interdisciplinary team members should be trained to act in cooperation with other. Corporate training is a dynamic process of disseminating knowledge and information to solve internal communication problems, during which employees of an organization receive and apply the acquired knowledge and practical skills in their work. It allows them to more successfully and effectively adapt to changes in the external environment, while developing new models of professional activity. In the conditions for the development of a modern hospital, people are the main advantage and strategic resource (Prakash, 2015). Therefore, corporate training of the entire team is necessary to solve the set strategic tasks. Based on expert assessments and research results, it can be argued that investments in the development of the team are the most useful among other investments and can significantly improve patient outcomes.


To conclude, it should be emphasized that the hospital lacking effective communication cannot be successful in discharging patients from acute care to home settings. Many patients face co-morbid diseases and even death due to poor discharge instructions, the discontinuity in medication intake, and other critical challenges. To address the gap between the inpatient care and post-discharge environment, it is beneficial to train the entire team and ensure that they understand the value of communication with each other. Also, the implementation of electronic health records is useful for accurate documentation of patient data and its transference between care providers. These interventions would create a culture of openness and trust between the members of the interdisciplinary team since they will be trained to properly discharge patients and cooperate with each other.


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Ahmed, Z., Saada, M., Jones, A. M., & Al-Hamid, A. M. (2019) Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), e0217023. Web.

Crisp, D. H. (2016). Anatomy of medical errors: The patient in room 2. Sigma Theta Tau.

Kushniruk, A., & Borycki, E. (2018). Safety and risk management for health information technology. Academic Press.

Marvin, V., Kuo, S., Poots, A. J., Woodcock, T., Vaughan, L., & Bell, D. (2016). Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital. BMJ Open, 6(6), e010230. Web.

McHaney, R. W., Reychev, I., Azuri, J., & Moshonov, R. (Eds.) (2019). Impacts of information technology on patient care and empowerment. Medical Information Science Reference.

Prakash, G. (2015). Steering healthcare service delivery: A regulatory perspective. International Journal of Health Care Quality Assurance, 28(2), 173-192.

Unruh, L., & Hofler, R. (2016). Predictors of gaps in patient safety and quality in US hospitals. Health services research, 51(6), 2258-2281.

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NursingBird. "Medical Errors at Mary Hill Hospital." March 10, 2022.