Medication Errors as Patient Safety Issue
According to Institute of Medicine (IOM), patient safety is “an indistinguishable element from delivery of quality of healthcare” (Makary & Daniel, 2016). Patient safety is an important element of an efficient and effective healthcare system and healthcare professionals are engaged in improving patient safety by learning from errors, checking procedures and through effective communication (Ulrich & Kear, 2014). These activities minimize patient harm and ensure safety in the healthcare organization. However, the scenario is different in my organization as there is increasing incidence of medication errors that is hampering patient safety. Moreover, many organizational barriers affect the quality of care and patient safety. Therefore, the following essay involves the discussion of medication error as patient safety issue, evidence-based interventions, technology use and strategies to overcome organizational barriers.
Medication errors are divided into four broad categories: lack of knowledge, rule and action- based errors and memory-based errors. Knowledge-based errors occur due to lack of communication between healthcare professionals regarding drug-dose information contributing to prescription errors. The second type of medication is rule-based error where medication is administered at the wrong route. The third type of error is action-based error. This is the most common type error as it occurs because of slips in attention at the time of dispensing, prescribing or drug administration. Technical error is a subset of this error type where there is wrong entry of amount of drugs. Lastly, memory-based errors where medical staffs administer wrong medicine forgetting about the medical history of the patient (James, 2013).
Although, progress has been made in the detection, reporting and learning from patient safety events, improvements are required for enhancing the patient safety and data quality in my organization. Medications errors are leading to poor quality of care and patient deaths that are otherwise preventable in my organization. In the present scenario, medication error is the major patient safety issue concerning my organization.
Medication errors are giving rise to many patient safety issues. Firstly, incomplete or inappropriate patient information where nurses do not make full entry of patient’s medical information on the chart. As a result, there is missing information that has a direct effect on the health and safety of the patient. The proper documentation of past medical history, current medications, allergies is important as it might alter the whole treatment procedure. Inaccurate drug information is another cause of medication error where nurses or caregivers are not aware of the current drug information due to lack of knowledge and skills (Vogelsmeier et al., 2013). Medication errors are also caused by inadequate communication between healthcare professionals. Miscommunication may occur due to heavy workload, power struggle and lack of situation awareness that compromises patients’ lives. Drug packaging, nomenclature or labelling is another cause of medication error. The delivery of improper medicines or same sounding or looking alike medicines during busy schedules is a common event for medication error hampering patient safety (Starmer et al., 2014). Another contributing factor to medication error is staff shortages and their lack of competencies. Many nurses may not be aware of the correct administration of drugs that also leads to medication error. Therefore, these factors greatly contribute to medication errors and adverse events causing unintended harm to patients resulting in compromising patient safety and large financial burden to the organization.
Organizational Barriers to Quality Improvement and Patient Safety
My organizational standards for addressing medication errors does not align with the principles, concepts and practices of World Health Organization (WHO) that contributes to patient safety and quality improvement. WHO outlines performance requirements or principles that acknowledge medication safety as one of the topmost priorities concerning patient safety. The use of generic names, tailoring of prescribing procedure for patients, learning and practicing medication history, knowledge about high-risk medications, familiarity with medications, following the concept of 5 Rs during prescribing and administration are some of the requirements. In addition, clear communication, reporting and learning from medication errors and encouraging patients to take an active participation in the medication process also helps to acknowledge that medication safety is of paramount importance (Aljadhey et al., 2013).
However, the scenario is different at my organization. The steps in medication use and practice involve prescribing, administration and monitoring as outlined by WHO. In my organization, prescribing go wrong in many ways. The nurses have inadequate knowledge about drug contraindications and not aware of patient’s medical history like allergies, co-morbidities and other medications. There is inadequate communication between the professionals that results in wrong dose, wrong patient and wrong time. Moreover, the documentation is incomplete, illegible and ambiguous. Mathematical error also occur at the time of dosage calculation and most importantly, incorrect data entry like omission, duplication or wrong number. In contrast to this, WHO recommends that while prescribing medication, medical staffs should choose an appropriate medication as per clinical situation considering patient’s medical history (Leotsakos et al., 2014). The selection of administration route, time, dose and regimen should be appropriate before prescribing medication. There should be proper documentation and communication between staffs regarding the medication administration and patient. To avoid sound-a-like or look-a-like medication mixing or ambiguous nomenclature, the medication should be written clearly with accepted local terminology, avoiding trailing zeros (1 instead 1.0) and using leading zeros (0.1 instead of .1) (Quélennec et al., 2013).
Wrong patient, time, route, drug, dose, omission or inadequate documentation makes drug administration go wrong. WHO recommends 5 Rs (Right Drug, Time, Route, Dose and Patient). Monitoring also goes wrong when nurses do not monitor the patients for side effects, drug levels with lack of follow-ups and communication failures. In contrast to these practices, WHO recommends continuous patient observation to look for medication working, appropriate used and ensure that no harm is caused to the patient with proper documentation of vital signs after drug administration (Bennadi, 2013).
Principles, Concepts, and Practices to Improve Patient Safety and Quality in Healthcare
Ethical and legal issues are associated with medication error. According to American Medical Association (AMA), nurses have the responsibility to address this problem to shape a culture of safety in healthcare. The ethical principles of autonomy, right to knowledge and disclosure, veracity, beneficence and non-maleficence are the main issues involved in medication errors. There is right to self-determination and autonomy where patients have the right to make their own choices and take actions that are based on perceived benefits and personal views (Bonney, 2013). Therefore, nurses have the responsibility to inform the patients about their ongoing treatment including a medical error that has occurred. The principles of non-maleficence and beneficence direct healthcare professionals to do what is best for the patients and avoid harm. They have the responsibility to reduce the possible harm caused by an error promoting patient safety. Moreover, healthcare professionals have an ethical obligation to provide information to patients for informed decision-making. The patient has the right for full disclosure in case of any medical error. Veracity principle explains that healthcare professionals should provide accurate, objective and comprehensive information to patients so that they understand it. Moreover, for the establishment of trust, they must tell the truth about medical errors through effective communication to the patients (Aldrich, 2013).
Evidence-based interventions are required for addressing the medication errors in my organization. The strategies involve maintenance of adequate nursing staff and pharmacist, improvement in nurses’ workflow, adoption of effective medication administration strategies, implementation of appropriate technology and fostering a culture of accountability where healthcare professionals should value quality improvement. Pharmacist staffing should be appropriate in context to medication preparation, laboratory values crosschecking, monitoring of high-risk and look-like medications (Kwan et al., 2018). Moreover, there should be active participation of healthcare professionals in addressing medication safety related to implementation of key safety practices: no use of abbreviated drug name in lists, use of two identifiers for drug administration, high drug alert and two independent checks for high alert dosages of medication.
For maintaining adequate nursing staff and workflow, the nurse to patient ratio should be taken into consideration. As nurses are involved in medication prescribing and administration, their workflow should be proper during administration and patient monitoring. Nurse to patient ratio should be proper as ANA recommends 1:1 or 1:2 so that there is no heavy workload or stress as that can result in medication errors (Shekelle, 2013). Effective medication reconciliation strategies are an evidence-based practice where the current medication regimen of a patient is compared against admission, discharge or transfer orders of a physician in identifying discrepancies. This concept combines the need for expert review and patient information of medications, side effects and interactions. Strategies like pharmacist-led accurate patient medication history, counselling, reconciliation, medication review, clearly defined roles and capacity building, discharge plan use help to reduce the cost of care related to adverse drug incidents (Hairr et al., 2014).
Conclusion
The most important strategy for reduction is medication errors are implementation of appropriate technology for administering, storing and monitoring of medications enhancing patient safety. The use of pertinent technological strategies like radiofrequency identifiers (medication storage), improved wristbands for better patient identification, computerized decision support (CDS) that provide alert for high dose and high–risk medications and surveillance systems that monitor drug administration and allow prompt identification of adverse drug incidents (Horsky et al., 2013). Furthermore, creation of an environment of quality is vital for achievement of medication safety. The healthcare professionals need to be accountable for their actions and should voluntarily report incidents of medication errors depending upon staffing and support.
Organizational support is important for creating a quality environment where healthcare professionals should learn from errors and encourages prompt and non-punitive incident reporting. Healthcare professionals should adhere to The United States National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) guidelines for improving quality of organizations and reduction in medication errors. In addition, Continuous Professional Development (CPD) of nursing staffs is crucial and the faculty should take new medications under their teaching domains keeping nurses updated in learning procedures and related policy guidelines (Kuo, Touchette & Marinac, 2013).
Medication errors can be prevented by using information technology (IT). As medication administration is the last step in medication management, the intercept rate is low. To memorize, recall, synthesize large amount of data and pay undivided attention during vulnerable areas that can avoid medication error, IT systems can be beneficial in improving organization and access to information. As maximum errors occur during prescribing step, patient-specific decision support with computerized physician order entry (CPOE) is a potential intervention for ensuring patient safety. Dispensing errors are also common and by using pharmacy-dispensing systems like automated dispensing cabinets and drug-dispensing robots, medication errors can be reduced (Agha, 2014). Errors in packaging, recognizing medications and dispensing can be reduced using bar codes. Bar-coded medication administration (BCMA) systems are helpful during bedside medication administration where they need to scan the identification bracelet of patient and unit medication dose. Electronic medication reconciliation can be used at transition care points, admissions and discharge; however, it cannot detect error caused by physician while prescribing medications to patient during discharge. Personal health records (PHRs) empower patients to take an active part in their medical care. PHR is a stand-alone portal for patients in entering their own medical data and give patients access to claiming EHRs (Taha et al., 2013). Therefore, these IT systems can be helpful in reducing medication errors.
References
However, there are certain organizational barriers to this change like lack of leadership, budget and resources, technology, resistance to change or skepticism, lack of communication and organizational culture. Healthcare professionals in the organization may resist change due to uncertainties and outcomes of change. Motivation through rewards and team-based problem-solving approach can be helpful in overcoming resistance from staffs. Enlisting of outside help in driving initial projects can be helpful in providing funding or shortage of internal resources. A communication plan can be helpful in reaching to all levels of organization and building through visible and early wins. Lastly, IT systems can be helpful in overcoming the barriers to medication errors at the time of prescribing, administration and monitoring by physicians and nurses. The healthcare professionals should be indulged in CPD for education and training in being adapted to the proposed change in my organization (Weller, Boyd & Cumin, 2014).
From the above discussion, it can be concluded that medication errors is one the major patient safety issues that is otherwise preventable in my organization. Medication use is a complex method and errors occur during medication steps of prescribing, administering and monitoring in my organization. Wrong dose, drug, time, patient and route, inadequate communication and knowledge, incorrect data entry, look-a-like or sound-a-like medicines can cause medication errors. WHO recommends using generic name appropriately, practicing medication history, 5 Rs, clear communication, encourage patients’ active participation and learning from medication errors can help to reduce medication errors.
References
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Aldrich, R. (2013). Open disclosure: Ethical and cultural considerations. In Legal and forensic medicine (pp. 1137-1158). Springer Berlin Heidelberg.
Aljadhey, H., Alhusan, A., Alburikan, K., Adam, M., Murray, M. D., & Bates, D. W. (2013). Medication safety practices in hospitals: A national survey in Saudi Arabia. Saudi Pharmaceutical Journal, 21(2), 159-164.
Bennadi, D. (2013). Self-medication: A current challenge. Journal of basic and clinical pharmacy, 5(1), 19.
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