Analysis of the Case Study
Health can be defined as a complete state of physical, mental, social, and emotional wellbeing of a person. It does not imply the absence of the disease but it indicates about the complete, state of wellness of the person throughout the life. Effective management in health is the area being highlighted here, which further states about the effect of health of an individual. There has been an analysis of a case study which describes about 40-year old women. The case study deals with the issues of communication in healthcare which resulted into the medication errors. These medication errors impacted the health and safety of the patients in healthcare settings. These medication errors are in terms of the wrong dosage of medicines, ineffective administration of the medicines, in the hospitals. Medication errors refers to failure in the treatment process that is capable of harming the patient, and cause serious illness, and other long-term effects on the physical, mental, and emotional wellbeing or wellness. Therefore, there are several incidents related to the medication errors and the occurrence of the issues in these Healthcare’s which impacts the management of health and health related problems of the individual (Spreen et al., 2014).
The case study brings about the discussion of 40-year old women, and her health conditions. She was brought to the ER (Emergency room), because of few issues. These issues were shortness of breath, rashes on her body due to the consumption of seafood. She faced the problem of the edema of throat, which included the inspiration of the mild stridor.
She was observed with the stridor, which is mainly identified in children more than adults. Stridor refers to a wheezing high-pitched sound which is often the result of the air-block. Airflow is usually blocked due to the disruption in the larynx or the wind pipe (trachea). The temperature readings of the patient were 98.7F, with the blood pressure as 100/69mm hg and the rate of pulse was identified as 70bpm. She was placed on the supplemental oxygen due to the problem of shortness of breath. Shortly being following the IV infusion, she complained about the chest pain in her body, and the tingling was felt in her finger-tips.
She was given with the 2 doses of the 0.4 mg sublingual nitro-glycerine for the next 10 minutes to make her heartbeat and the blood pressure reached to normal. An ECG was followed and it represented an elevation of the ST, and after the subsequent ECG it was observed that her ST reached to the baseline. After further observation of the situation, it was found that the women/patient in the case was given wrong injection. The patient received IV dose of epinephrine, instead of the standard IM injection of epinephrine for anaphylaxis. The dose of the IV of epinephrine is used and reserved in the cases of the patients with the ‘Myocardial infarction’. In the represented case the issue of the medication error is highlights as “Medication error Right Drug, Wrong Route” . Epinephrine exerts the effect or the influence on the heart, vascular, and the other muscles in the human body (Campbell et al., 2015).
Medication Errors in Healthcare
It has been identified and analysed as a reason for both, anaphylaxis and myocardial infarction. Also, it is available in number of concentrations and doses, and is controlled or administered with the varying nature of routes specific to each indication. Doctors, nurses and the pharmacists must be aware of the different combinations and concentrations available so that they avoid mistakes in medication. They must know what concentration means in the medication system and which is specific in the given situation for the patient. It has also been observed that sometimes there is a possibility of the errors in the wrong reading of the concentration because of the zeros (de Silva et al., 2015).
The above statements also defined the issue of the case with the patient’s health condition. Medication error in this case is the preventable event which was caused due to the failure of an action or the wrong dosage of medication that results in the injury or in serious case death of the patient. It has been studied as per the increasing cases of the medication errors in the hospitals, that these can be easily prevented by human efforts. 25% of the medication errors are preventable, from proper administration of the medication. The occurrence of the medication errors does not have specific form, these can occur anywhere. Medication error can occur right from the beginning i.e. from the prescription process, to the illegible physician handwriting, inaccurate transcription, and the wrong or improper administration of the medication given to the patients (Debono et al., 2017).
Medication errors are sometimes very severe which impact of influence negatively the state of health of the person, causing long-term illness. These errors are committed by the human, which include mistakes done by any staff member of the hospital, professional or non-professional staff of the hospitals. The medication errors in the hospitals cause increase in the number of days of the patients in the hospital for their treatment. In addition to the increase number of days in the hospital, the costs of services in the healthcare also increases. This affects the patients and the organisation (healthcare) as a whole in the effective management of health (National Academies of Sciences, Engineering, and Medicine, 2016).
Discussing all the terms and the aspects related to the symptoms and conditions of the women in the case, it has been understood that the events of the medication errors in the healthcare are mainly affected by the mismanagement in the organisation. The mismanagement in any term can be the cause of the medication error. Relating to the topic mentioned above, these preventable medication errors are also the result of the poor communication between the healthcare professionals, or between the healthcare professional and the patient (Scott et al., 2018). Also, due to the lack of the knowledge related to the medicines and the doses to be given and the miscalculation of the doses. As now even computers and the electronics are not infallible, mistakes can take place even with their usage in the healthcare settings. Therefore, humans or the staff in the healthcare or nursing must specially incorporate electronic medication system or improvements in their system of medication. The improvement in the system of medication will facilitate the prevention of these controllable errors and ensure effective management of their health (Borkowski, 2015).
Preventing Medication Errors
Communication issues in healthcare resulting into medication error
As I was experiencing several communication issues in healthcare leading to medication errors so I had a quest for knowing the factors responsible for their occurrence. This might help me in resolving them by applying certain management theories on the same. So in week 1, I had researched upon the nature of occurrence of the medication errors.
According to my opinion, the main reason was improper, economically inefficient and ineffective usage of pharmaceuticals by the staff in health care organizations resulted into health issues. The medication errors are not only clinically significant in many incidences but they also have some serious economic implications like additional treatment of the patient, extended hospital stays and negligent proceedings. So medication errors are preventable incidences which may lead to inappropriate medicinal use whilst the medication is managed by patient or a health care professional. Such events may be associated with professional practice, health care products and systems like inappropriate order communication wrong labelling of products and packaging,nomenclature, dispensing , distribution , management , education , monitoring and usages (Weaver, Dy & Rosen, 2014).
I found that most of the medicinal errors were latent in nature. When the medical practitioner has prescribed the wrong medicine to the patient, he typically realizes when the patient has taken the first dose at his home. So the latent errors are accidents which are waiting to happen. As in the given case, the patient was given IV dose of epinephrine instead of the standard IM injection of epinephrine for anaphylaxis (Andersen et al., 2016).
The factors of medication errors amount to incomplete information of the patients i.e. unawareness about the medicines or products to which they are allergic or what other medicines they are taking .They also quantify to their previous diagnosis and lab results of the same . The other factors can be unavailability of information of the drug like lack of up to date warnings and miscommunication of the drug orders like in this case (Pham et al., 2012).
It might be caused due to poor handwritings or oral communications and confusion between the medicines with similar names. The staffs often gets confused between metrics and other dosing units and their improper abbreviations .Perhaps this was the cause of improper medication of the lady who had suffered from shortness of breath and rashes due to ingestion of sea food.
In the next week after knowing the factors responsible for medication errors, I came across certain causes of issues in communication in healthcare resulting into medication error. There could be error relating to lack of proper labeling in the preparation of drugs and repackaging into small units or the environmental factors like heat, noise, lighting, interruptions which can distract the health professionals from their tasks resulting into improper dosages to the patients might be responsible for the same (Meuter et al., 2015).
There could be a wrong interpretation of medicines as prescribed by the doctors by the staff. There could be an inaccurate calculation of doses in this particular case. I believe that the dispensing errors are associated with errors of commission i.e. dispensing the incorrect doses and those with omission i.e. failures to council the safe use of medicine (Van Cott, 2018).
Impact of Medication Errors on Effective Management in Health
These errors involve dispensing of an incorrect medicine, strength, and form of dosages. The drugs with similar names can often cause confusion. Adding on to the misery, the drugs with erroneous verbal medication orders and ineligible prescription can be one of the major causes of wrong dosages (Huckvale et al., 2015).
The other causes for errors can be too many telephone calls or due to overloading. There can be numerous patients due to which there can be lack of concentration amongst the staff. There might be unavailability of staff to double check the prescribed medicines or the dosages which are to be given to the hospitalized patients. Furthermore, it is possible that there was a time constraint amongst the staff so there was no body to counsel the patient (Weller, Boyd & Cumin, 2014).
I support the point that there might be poorly designed technology which may lead to wrong dosages and lack of accessibility to drugs by the medical personnel. There can be miscalculations of dosages by the doctors. It may also occur due to lack of proper information to the prescriber’s and lack of availability of information of the patients to the medical staff (Bogner, 2018).
It is a common phenomenon that the patients fail to understand the therapy as most of them are not from medical background. These errors also occur due to the failure of the staff to follow the instructions given on the label of the medicines. So by the end of this week I had gained intense knowledge about the causes of communication issues resulting into medication error in health care( Thakur, Hsu & Fontenot, 2012 ).
The third week started with analysis of the consequences resulting from improper dosages on the patient due to communication issues as per the give case study. The patient received a dose of IV epinephrine instead of a standard injection of epinephrine for anaphylaxis. So the consequences relating to epinephrine which may intensify the risk of error in dosages and the management of prescribed medicines can be that the dose of epinephrine which is used for heart attack is much more than the dose of anaphylaxis . The factors associated with medical errors related to epinephrine can be their availability in various concentrations viz. 1:1,000and 1:10,000 .So, there is always a possibility of misreading the concentration due to zeros (Wood, Traub & Lipinski,2013).
Overmedication and under medication can result to serious problems for the patients. Some of them comprise of chronic pain, deterioration in the current condition and slowing down in recovery of patients. It can often lead to new illness or other medical complications. It may also lead to failure in the organs or accumulation of toxic substances. These all may have a negative influence on the families of the patients, the staff and facilities provided in the hospital (Garon, 2012).
The inaccuracy and incompleteness of the information may lead to delays in care caused because of time consuming process of gathering and reconciling of data needed to apply a plan of care. These delays were worsened due to limitations which were inherent in the environment such as lack of an on-site pharmacy along with the requirement of special order equipment i.e. a specialty bed in advance.
It can lead to putting the patients at an increased risk of mobility and re hospitalization. Moreover, it also leads to delay in obtaining opioid borders of prescription because of lack of signed and hard copied prescriptions. The constant shift of care strategies and ambiguous care needs can produce workflow disruptions and inefficiency amongst the medical staff. It can often to death of the patients (Leape et al., 2012).
They are being unable to respond to the needs of the patients on time which can weaken the confidence and trust of the patients and their families. So as per my opinion, it is crucial to detect the communication issues which may lead to medicinal errors because they can occasionally turn out to be serious (King et al., 2013).
Addressing the issue stated in the case study of 40year old women, I came to an understanding that these issues can be effectively resolved using management theories in the healthcare. These theories of management relates to the issues and practices in every organizational set-up. According to my observation, and the analysis of the problems in the case, it has been understood that the major cause of medication errors was the communication issues in the healthcare. A number of management theories can be applied here which provides a guideline to be followed in the case (Woods et al., 2017).
System theory of management
According to my perspective on the system theory of management, patient safety and the quality of healthcare is the most important and the urgent property/entity of the whole healthcare system. The theory describes that the healthcare outcomes are improved on the systematic appreciation of the whole system. Therefore, implications of the system theory of management suggest ways to solve the problems in healthcare. The systematic management of the operations and issues helps the professionals as well as the staff or employees in healthcare. As they are now aware of their work, how it is to be done, and in what manner, it simplifies their duty in hospitals (Geisler & Wickramasinghe, 2015).
The other theories which can be applied in healthcare and avoid occurrence of similar cases further include systematic management theory and bureaucratic management theory. The systematic management theory aims to improve organizational effectiveness in longer term. This is done by analysing past data and focusing on current strategies or operations through advancement of organizational culture (Waring, 2016).
Human relations theory
The application of the human relation theory studied that how an organization manages and interacts with their employees in their operations so as to improve employee effectiveness. This will in turn enhance the effectiveness and performance of the organization as a whole. The theory will tend to improve the relationships of healthcare professionals with their employees, which will motivate them towards delivering better services and avoiding such errors (Duckett & Willcox, 2015).
Further discussing the applications of the above theories of management in healthcare settings, to improve patient safety and wellbeing, a number of things are suggested. A healthcare in Australia must follow the code of conduct or healthcare standards in order to avoid any intervention from the governmental bodies and issues in patient’s health. The commission developed the standards which follow the public and the stakeholder consultation. This is called as The National Safety and Quality Health Service Standards, and these standards are the critical components of the Australian Health Services safety and Quality Accreditation Scheme. These standards include certain standards such as governance for safety and quality in health Service organizations. Partnering with consumers, taking care of medication safety, and identifying patient and matching the procedure is another major standard. The Australian code of conduct of healthcare also states preventing and controlling infections. To eradicate the communication barriers in healthcare it is essential to develop verbal and non-verbal skills of communication with respect to the dignity, and morale of the patients. Thus, it will help in improving the communication between the health/nursing professionals and the patients, leading to reduced medication errors.
Conclusion
From the above discussion on the healthcare and patients and related aspects and concepts, I have analysed that ineffective communication leads to poor results. It results in poor and error prone care to the patients. Ineffective communication in the healthcare between health professionals and patient results in the development of negative feeling or attitude in the minds of the patients. As referred from the reflective journal it has been observed that there are number of issues such as medication errors, disappointment in patients/consumers, wrong medication, improper dosage suggested affecting the patient. Therefore, a number of management theories and concepts to devise methods and strategies to resolve such cases and prevent major illness or health issues. Hence, managers in healthcare need to analyze the situation and implement the required organizational theory to achieve positive outcomes, and ensure the patient safety and wellness.
References
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