Plan Proposal For Medication Errors

CAPELLA UNIVERSITY

SCHOOL OF NURSING AND HEALTH SCIENCES

Mar 2021

Content

NURS FPX4010 Assessment 4: Stakeholder Presentation

• Organizational and patient issue of medication errors
• Evidence-based interdisciplinary plan
• Implementing interdisciplinary plan
• Managing human and financial resources
• Evidence-based criteria to evaluate success of plan
• Evidence-based criteria to evaluate the outcomes

NURS FPX4010 Assessment 4: Stakeholder Presentation

Medication errors

• Near misses and adverse effects may harm the patients
• Medication errors are one of the major reasons for adverse effects
• The errors affect organizational functions and processes 
• Medication errors increase work burden
• Medication errors lead to blame culture and conflicts
• It is difficult to identify errors at times

Types of medication errors

• Ordering or prescription errors
• Transcribing errors
• Documenting errors
• Dispensing errors
• Administering errors
• Dosage errors

NURS FPX4010 Assessment 4: Stakeholder Presentation

Effects of medication errors

• Delayed care
• High cost of care
• Mortality and morbidity
• Long-term side effects
• Sense of guilt, disappointment, fear and inadequacy
• Lower patient trust 

PDSA Cycle

• Plan
  • Identify and create a team
  • Create aim and objectives
  • Analyze current approach
  • Identify potential interdisciplinary solution

NURS FPX4010 Assessment 4: Stakeholder Presentation

Evidence-based interdisciplinary plan

• Do phase
  • Role-based interdisciplinary team
  • Error reporting system with physician order entry
  • Direct communication channel in reporting system
  • Checklist to compare prescription, EHR, dosage, and medicine
  • Bar-code-based medication system
  • Shared decision-making with root-cause analysis

Evidence-based interdisciplinary plan

• Report any changes in packaging or brand
• Do not use abbreviations
• Limit interferences during drug administration through
  • Tabards
  • Nurse collaboration 
• Communication protocols for faster response

Study and Act Phase

• Examine the results to check
  • Analyze error rates
  • Calculate response rate
  • Compare cost with benefit
  • Analyze burnout and perspectives
  • Analyze patient satisfaction
  • Observed side-effects
  • Identify need for change

Managing Financial & human resources

• Motivate the health care professionals to increase performance
• Increase nurse to patient ratio
• Manage burden and schedule the work
• Solve conflicts
• Provide support, incentives, and resources
• Procure error reporting, bar-code, and checklist system
• Manage finances without compromising with quality of care

NURS FPX4010 Assessment 4: Stakeholder Presentation

Criteria to evaluate success

• Reduced medication errors
• Increase in response rate
• Reduction in cost
• Reduction in burnout
• Increase in patient satisfaction

Criteria

• Faster root-cause analyze
• Increase in effective communication
• Higher job satisfaction
• Increased trust in patients
• Increased computer science competencies and skills 

NURS FPX4010 Assessment 4: Stakeholder Presentation

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, bar-code, tabards to reduce interferences, a checklist for verification, and education and training staff are beneficial in reducing errors and promote quality culture. 

References

• Bosma, B., Hunfeld, N., Roobol-Meuwese, E., Dijkstra, T., Coenradie, S., & Blenke, A. et al. (2020). Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands. International Journal Of Clinical Pharmacy, 43(1), 66-76. https://doi.org/10.1007/s11096-020-01101-5
• Desai, M., Patel, N., Shah, S., Patel, P., & Gandhi, A. (2016). A study of medication errors in a tertiary care hospital. Perspectives In Clinical Research, 7(4), 168. https://doi.org/10.4103/2229-3485.192039
• Kang, H., Park, H., Oh, J., & Lee, E. (2017). Perception of reporting medication errors including near-misses among Korean hospital pharmacists. Medicine, 96(39), e7795. https://doi.org/10.1097/md.0000000000007795
• Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administration safety by reducing distractions and interruptions. Journal Of Nursing Care Quality, 35(4), E58-E62. https://doi.org/10.1097/ncq.0000000000000473
• Musharyanti, L., Claramita, M., Haryanti, F., & Dwiprahasto, I. (2019). Why do nursing students make medication errors? A qualitative study in Indonesia. Journal Of Taibah University Medical Sciences, 14(3), 282-288. https://doi.org/10.1016/j.jtumed.2019.04.002
• Palese, A., Ferro, M., Pascolo, M., Dante, A., & Vecchiato, S. (2019). “I am administering medication—please do not interrupt me”: red tabards preventing interruptions as perceived by surgical patients. Journal Of Patient Safety, 15(1), 30-36. https://doi.org/10.1097/pts.0000000000000209
• Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal Of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235
• Schmidt, K., Taylor, A., & Pearson, A. (2017). Reduction of Medication Errors: A Unique Approach. Journal Of Nursing Care Quality, 32(2), 150-156. https://doi.org/10.1097/ncq.0000000000000217
• Stewart, D., MacLure, K., Pallivalapila, A., Dijkstra, A., Wilbur, K., & Wilby, K. et al. (2020). Views and experiences of decision‐makers on organisational safety culture and medication errors. International Journal Of Clinical Practice, 74(9). https://doi.org/10.1111/ijcp.13560
• 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

NURS FPX4010 Assessment 4: Stakeholder Presentation