Analyzing a current health care problem or issue

Medication errors 

The mortality rate due to different medication errors in the United State is between 7,000 and 9,000. Medication errors leading to adverse effects can easily cross hundreds of thousands of patients. Medication errors increase health care costs by $40 billion for every 7 million patients every year (Tariq et al., 2020). As a result, it is critical to address the issue to increase patient satisfaction, quality care, nurse competencies, coordination between health care and pharmacies, and establish a high-performing health care facility. The purpose of this paper is to analyze the medication error problems and solutions to mitigate them to propose and provide an action plan to implement the solution by considering its effectiveness and ethical implications. The paper first identifies different factors and elements that are associated with the issue, effects of these factors and issue, different types of medication errors, different solutions adopted by health care institutions, critical analysis of the solutions, proposed solution, its ethical consideration, and evidence-based change implementation model to implement and evaluate the solution.  

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue

Elements of the problem/issue

Medication errors can have either be harmful or harmless, but it decreases the quality of care, increases conflict between health care professionals, pharmacy, medical transcriptionist, and other stakeholders (Thompson et al., 2018). Also, it reduces the trust of patients in health care. The elements of the problem are packaging errors, prescription errors, dispensing errors, drug administration, poor communication, and adverse drug reactions (Hammoudi et al., 2017). 

Packaging errors are of two types. The first one is related to poor printing and wrong information. Wrong information includes dosage, similar names, and chemical composition errors. This issue can only be resolved if the nurses observe adverse effects and report the effect to investigate the medication if the package has the right information, but the wrong product or vice versa (Gilmartin-Thomas et al., 2017). Also, dispensing unit can identify it if there are minor errors on the packaging. This error can lead to increased health complications and pose threats to the patients as medicine can be completely different due to packaging errors (Brass et al., 2018). The probability of errors is moderate.

The second type of error is related to a frequent and sudden change in the original packaging, name series, and color of the medicine. A study by Gilmartin-Thomas et al. (2017) that medication errors were observed after a change in packaging. It creates confusion among nurses due to a lack of communication between pharmacists and nurses regarding change of packaging (Brass et al., 2018). The probability of errors is moderate. 

Prescription errors ranged from 6% to 77.7% (Korb-Savoldelli et al., 2018). These errors are highly likely and they are related to lapses, mistakes, and errors in calculation due to similarities in pharmaceuticals and drug names, wrong and incomplete patient and drug information on prescription, and computerized physician order entry (CPOE) (Kadmon et al., 2017). Dispensing errors and prescription errors are related to discrepancies between the medicine delivered to patients or wards and the prescription (Abdel-Qader et al., 2020). The errors can vary from 1.25% to 45% (Kumar et al., 2019). 

Drug administration errors are mainly because of the wrong time of administration, wrong dosage and omission, wrong administration rate, wrong preparation, and administering medicines from dispensing error without verifying and contacting pharmacy dispense unit (Palese et al., 2019). The error rate varies from 8% to 25% and most of the errors are from nurses (Suclupe et al., 2020). Drug administration errors can result from interferences during administration time and individual errors. These errors are likely to occur because of increased turnover rate and patient count. 

Poor communication results in increasing the medication error chances as preventive and corrective actions cannot be implemented. This further creates a gap between prescription, dispense, and drug administration units leading to blame culture and conflicts. adverse drug reactions. Communication failures include no acknowledgment, poor suggestion, improper information, and delayed response (Hohenstein et al., 2016). This error is highly likely as dependence on prescription and dispensing software can lead to lower communication. 

Analysis of the problem or issue

Medication errors are defined as any preventable events that may lead to patient harm leading to adverse effects. Adverse effects are defined as negative drug reactions, which can be unintended, undesired, and noxious. An adverse drug event is defined as an injury from improper dosage, administration, and other errors. Injury can be morbidity or even mortality (Tariq et al., 2020). 

As medication errors affect patient security, as a nurse, it is my job to limit such errors to increase patient safety. Further, such errors increase hospital costs s health care has to treat the adverse event (Tariq et al., 2020). Thus, it increases hospital stay and readmission rates. Such errors further increase the burden on nurses as the nurse-to-patient ratio decreases (Suclupe et al., 2020). Errors can lead to disciplinary actions and at times, legal actions (Tariq et al., 2020). This decreases the trust of the patient in health care indicating that the health care facility has low quality of care. As a result, the problem is important. 

Effect on patients

All the medication errors can affect the patients negatively. Negative effects are not just limited to primary or secondary health concerns, but effects also include psychological concerns as patients who contract other diseases and infections during a hospital stay are at higher risk of becoming stressed, anxious, and depressed (AbuNaba’a & Basheti, 2019). For example, patients develop “I Just Don’t Care” and lack of desire in getting treatment for similar symptoms after adverse drug events. This indicates that medication errors lead to adverse effects and adverse effects lead to psychological issues (Zolnoori et al., 2019). 

Further, adverse effects increase the financial burden on the patients as patients have to stay longer and go under treatment to negate the adverse effects (Poudel et al., 2017). Some adverse effects lead to lifelong medical conditions and some lead to morbidity or mortality. For example, a woman admitted to Midwestern state died after a pharmacy tech who did not have formal education or training made numerous transcription errors. The errors included ten-times dosage rate, misspellings, and incorrect patient information (Fink, 2019). 

Effects on nurses and other health care professionals

Poor job satisfaction is the overall adverse effect of the medication issue as increased medication errors represent poor professional behavior. Blame culture is fairly common in health care as different units such as pharmacy, dispense units, nursing staff, physicians, and other health care professionals involved in medication error conflicts. Conflicts lead to anxiety and depression in nurses as the work environment will not be supportive (Muir-Cochrane et al., 2018). For example, the death of a patient due to high dosage will create conflict. Finding root-cause takes time due to different units. As nurses are at the lower end of the chain they will get blamed first resulting in fear and poor mental health and lower job satisfaction (Afolalu et al., 2021). 

Considering options solutions, responses, or answers

The first solution is to establish direct communication between nurses, physicians, pharmacists, and suppliers to reduce the likeliness of errors in prescription, dosage calculation, dispensing errors, and delayed drug administration. This can be achieved by integrating medication error reporting and cross-verifying information with EHR and documentation. The second solution is to provide checklist software for each unit to make sure everything is verified before proceeding to the next step. Pharmacists need to verify medicine name, dosage, brand, and patient information. It can be achieved by implementing a bar-code-based medication system to reduce typing and transcription errors (Thompson et al., 2018). The third solution is to educate everyone regarding the use of abbreviations. For example, QD (once a day) can be misinterpreted with QID (four times every day) or any other abbreviation. It is better not to use the abbreviation to reduce medical errors. The cons of these solutions are they require a new system, resources, and may lead to over-dependence on technology. 

The next solution is to implement a communication protocol with error reporting software so that remarks on particular medicine and patients can be made for a quick resolution. Also, the use of a medical device with separate sections for medicines and voice tags to determine the content of the syringe reduces dosage errors (Wu et al., 2020). Communicating with nurses and physicians about change in packaging help in reducing confusion and delay in drug administration. The problem of interferences during administration can be reduced by using tabards with different signs. This reduces the number of interferences resulting in less errors. Further, nurses need to verify medicine with EHR and patient checklists to determine whether the right medicine is administered or not (Trakulsunti et al., 2020). Another important aspect is to train and educate the stakeholders to increase interprofessional collaborations (Abdel-Qader et al., 2020). Two cons are information confidentiality and unwanted errors leading to delay in treatments.

Failing to implement the solutions and ignoring the problem will result in different consequences such as patient morbidity and mortality (Gilmartin-Thomas et al., 2017), secondary health problems, increased health care cost, increased hospital readmissions, negative psychological effects on patients and staff, ethical, professional, and legal implications, increased conflicts, and lower satisfaction in patients and health care staff (AbuNaba’a & Basheti, 2019). 

Solution 

The best solution is to integrate all of the above solutions in one system as different solutions are for different errors. Tabards are for drug administration errors, EHR and electronic checklists are for verification, integrated reporting and communication software to monitor prescription, dispensing, and communication, devices, label, and voice tag for dosage calculation, a bar-code-based system for medicine information, and educating health professionals to communicate and collaborate to prevent errors and find root-causes for errors. 

Ethical implications and implementation of the potential solution

Ethical implications include professional practice to protect patient information, beneficence – doing what’s right, non-maleficence – do not harm the patient, fair-use of technology, truth-telling to reduce blame culture, and fulfill the responsibility fully and effectively to reduce human errors (O’Rourke et al., 2019). For example, truth-telling over fear and blame culture after a medication administration error helps in quickly attaining the patient, reducing adverse effects, reducing workplace conflicts, promoting patient well-being, and finding root-causes. The system has integrated all solutions from the above section. As a result, it has all the cons and pros along with increased complexity in the system at first as different solutions are integrated. It is important to adopt EBP systems for change such as the Iowa EBP model to implement the proposed solution as the model help in analyzing the problem, finding the best possible way of implementation, collaboration, and research, applying solution at a micro level, evaluating the outcome, and implement the change at the macro level or propose new changes. Further, the solution requires new infrastructure, IT services, and policies and protocols (Buckwalter et al., 2017).

 

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue

Conclusion

Medication errors include prescription, dispensing, dosage calculation, and drug administration errors. As stakeholders’ units are involved, an integrated system with EHR, medication reporting and communication, device for dosage calculation, tabards to reduce interferences, a checklist for verification, and education and training staff are necessary. The system includes beneficence, non-maleficence, truth-telling, professional conduct, and practice. EBP models such as the Iowa model are necessary to implement the solution and evaluate its impact successfully.  

References

Abdel-Qader, D., Meslamani, A., Lewis, P., & Hamadi, S. (2020). Incidence, nature, severity, and causes of dispensing errors in community pharmacies in Jordan. International Journal Of Clinical Pharmacy, 43(1), 165-173. https://doi.org/10.1007/s11096-020-01126-w

AbuNaba’a, Y., & Basheti, I. (2019). Assessing the impact of medication management review service for females diagnosed with depression and anxiety: A randomized control trial. Journal Of Evaluation In Clinical Practice, 26(5), 1478-1489. https://doi.org/10.1111/jep.13314

Afolalu, O., Jordan, S., & Kyriacos, U. (2021). Medical error reporting among doctors and nurses in a Nigerian hospital: A cross‐sectional survey. Journal Of Nursing Management. https://doi.org/10.1111/jonm.13238

Brass, E., Reynolds, K., Burnham, R., & Green, J. (2018). Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements. Academic Pediatrics, 18(5), 563-568. https://doi.org/10.1016/j.acap.2018.03.001

Buckwalter, K., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A., & Rakel, B. et al. (2017). Iowa model of evidence-based practice: revisions and validation. Worldviews On Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Fink, J. (2019). Family cannot seek damages after patient dies due to wrong medication. pharmacy times. Retrieved 15 February 2021, from https://www.pharmacytimes.com/publications/issue/2019/September2019/dispensing-wrong-medications-leads-to-patients-death.

Gilmartin-Thomas, J., Smith, F., Wolfe, R., & Jani, Y. (2017). A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: A prospective observational study. International Journal Of Nursing Studies, 72, 15-23. https://doi.org/10.1016/j.ijnurstu.2017.03.008

Hammoudi, B., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal Of Caring Sciences, 32(3), 1038-1046. https://doi.org/10.1111/scs.12546

Hohenstein, C., Fleischmann, T., Rupp, P., Hempel, D., Wilk, S., & Winning, J. (2016). German critical incident reporting system database of prehospital emergency medicine: Analysis of reported communication and medication errors between 2005-2015. World Journal Of Emergency Medicine, 7(2), 90. https://doi.org/10.5847/wjem.j.1920-8642.2016.02.002

Kadmon, G., Pinchover, M., Weissbach, A., Kogan Hazan, S., & Nahum, E. (2017). Case not closed: prescription errors 12 years after computerized physician order entry implementation. The Journal Of Pediatrics, 190, 236-240.e2. https://doi.org/10.1016/j.jpeds.2017.08.013

Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal Of Medical Informatics, 111, 112-122. https://doi.org/10.1016/j.ijmedinf.2017.12.022

Kumar, S., Ramankutty, A., & Jayachandran, S. (2019). A prospective study to evaluate awareness among healthcare personnel about medication errors in a tertiary care teaching hospital. Indian Journal Of Pharmacy Practice, 12(4), 244-249. https://doi.org/10.5530/ijopp.12.4.52

Muir-Cochrane, E., O’Kane, D., & Oster, C. (2018). Fear and blame in mental health nurses’ accounts of restrictive practices: Implications for the elimination of seclusion and restraint. International Journal Of Mental Health Nursing, 27(5), 1511-1521. https://doi.org/10.1111/inm.12451

O’Rourke, D., Thompson, G., & McMillan, D. (2019). Ethical and moral considerations of (patient) centredness in nursing and healthcare: Navigating uncharted waters. Nursing Inquiry, e12284. https://doi.org/10.1111/nin.12284

Poudel, D., Acharya, P., Ghimire, S., Dhital, R., & Bharati, R. (2017). Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database. Pharmacoepidemiology And Drug Safety, 26(6), 635-641. https://doi.org/10.1002/pds.4184

Suclupe, S., Martinez‐Zapata, M., Mancebo, J., Font‐Vaquer, A., Castillo‐Masa, A., & Viñolas, I. et al. (2020). Medication errors in prescription and administration in critically ill patients. Journal Of Advanced Nursing, 76(5), 1192-1200. https://doi.org/10.1111/jan.14322

Tariq, R., Vashisht, R., & Sinha, A. (2020). Medication dispensing errors and prevention. Statpearls Publishing. Retrieved 18 February 2021, from https://www.ncbi.nlm.nih.gov/books/NBK519065/.

Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001

Trakulsunti, Y., Antony, J., Dempsey, M., & Brennan, A. (2020). Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study. International Journal Of Quality & Reliability Management, 38(1), 339-362. https://doi.org/10.1108/ijqrm-10-2019-0334

Wu, X., Ye, G., & Guo, L. (2020). A novel device to prevent errors in medication dosing and dispensing. Translational Pediatrics, 9(2), 133-136. https://doi.org/10.21037/tp.2020.02.05

Zolnoori, M., Fung, K., Patrick, T., Fontelo, P., Kharrazi, H., & Faiola, A. et al. (2019). A systematic approach for developing a corpus of patient reported adverse drug events: A case study for SSRI and SNRI medications. Journal Of Biomedical Informatics, 90, 103091. https://doi.org/10.1016/j.jbi.2018.12.005

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue