How Nurses Can Prevent Medication Errors

Quality and Sustainability Paper Part Two - Identifying Opportunities to Reduce Medication Error Rates by Nursing Staff
As reported previously, medication errors can occur in virtually any treatment setting, including patients’ homes, but the problem is especially pronounced in hospitals where the adverse reactions caused by medication errors can result in extended inpatient stays or even death. As also reported previously, nurses account for the largest percentage of medication errors, and these errors affect more than 7 million patients, cost nearly $21 billion and cause more than one million emergency room visits and three-and-a-half million visits to doctors’ offices each year. The purpose of part two of this study is to provide an overview of a selected nationwide health care organization and a description of its successes and failures in reducing medication error rates. In addition, this part of the study identifies a quality area in which nursing science can have a significant positive impact and the variables that should be used to evaluate its effectiveness. Finally, a discussion concerning potential obstacles that may hinder the implementation of the quality or safety measure and those groups or leadership roles within the entity with whom collaboration will be needed is followed by a summary of the research and important findings concerning the role of nursing staff in reducing medication errors in the conclusion.
Review and Discussion
1. Identification of a health care entity
The real-world organization of interest, hereinafter referred to alternatively as the “XYZ Health Care Organization” or just “XYZ,” operates the nation’s largest health care network. Established in 1930 in response to the growing demand for health care services for those individual who served in the United States armed forces, the XYZ Health Care Organization is a Cabinet-level federal agency that is responsible for the provision of the entire range of modern medical care services for eligible patients. At present, XYZ employs more than 377,000 health care workers, operates a network of 170 tertiary health care facilities and more than 1,240 outpatient clinics that provide services to more than 9 million patients each year (About XYZ, 2018). The formal mission statement for XYZ was taken directly from President Lincoln’s Second Inaugural Address wherein he called for the organization “to care for him who shall have borne the battle and for his widow, and his orphan” (The origin of the XYZ motto, 2018, p. 1). Given the enormous number of patients treated each year in the XYZ Health Care Organization’s facilities, it is not surprising that errors in medication administration occur, and these issues are discussed further below.
2. Using defined quality outcomes and/or patient safety measures, describe the health care entity's successes and failures. Include identified criteria and data that demonstrate why this entity is successful and in what areas.
The quality outcomes related to the reduction of medication errors by XYZ focus on identifying when, where, who, and why they were made to identify opportunities for improvement. The current criteria used by XYZ for patient incident reporting are as follows:
· Suicide
· Suicide Attempt
· Sexual Assault
· Homicide
· Patient Abuse
· Alleged
· Proven
· Fall
· Transfusion Error
· Medication Error
· Injury Not Otherwise Listed
· Fire, Patient Involved in
· Assault, Patient to Patient
· Assault, Patient/Staff
· Death
· Operating Room
· Recovery Room
· During Induction of Anesthesia
· Within 48 Hours of Surgery
· Conjunction with a Procedure
· Cases accepted by the Medical Examiner
· Equipment Malfunction
· On Medical Center Grounds
· Failure to Diagnose or Treat
· Other
· Missing Patient
· Informed Consent, Failure to Obtain (Incident reporting, 2015).
In addition, institution-specific ad hoc criteria are also used by various XYZ medical centers depending on what types of adverse events are most common at their facilities. These data are collected on the health care facility’s computer network together with information concerning the time and location of the incident, who was responsible (if known), and other relevant details in a narrative format. While the severity of isolated incidents of medication errors vary widely, the most common medication errors, accounting for 41%, involve the administration of improper dosages (Stoppler & Marks, 2018).
The XYZ Health Care Organization requires all employees, including health care providers, to report medication errors. In response to persistently high medication error rates in the past, XYZ implemented a quality improvement initiative to reduce these rates. The findings of a recent XYZ study indicate these efforts are having the desired effect. For example, according to one XZY nurse practitioner, “The rate of reported actual adverse events per month [during the period from mid-2006 to 2009] and the severity of those events has significantly diminished” (as cited in Bellum, 2018, para. 3). In sum, the nationwide rate of medication errors declined from 3.21 adverse events to 2.4 adverse events during the aforementioned reporting period, a clear indication that the initiatives undertaken pursuant to the quality improvement program were having the desired effect (Bellum, 2018). Even one life-threatening medication error, though, is one too many, but the XYZ nursing staff can help reduce these rates even further using the strategies discussed below.
3. Using the quality outcomes data, identify a quality or safety area that nursing science can impact. Describe the specific variables.
The quality outcomes criteria listed above include just one indicator for medication error without elaboration with respect to type, place, time and responsible individual, if known. This data is typically entered in the narrative section of the patient incident reporting form and varies depending on the individual inclinations of the reporter. This lack of standardization in reporting and the absence of supplemental data concerning medication errors diminishes the utility of this data in identifying trends and opportunities for improvement. Therefore, nursing service directors should implement a supplemental medication error reporting form printed on the reverse of the existing form that includes the following information:
Ward/unit _____________________
Time/shift: _____________________
Type of medication error:
? Wrong dosage
? Wrong patient
? Wrong route of administration
? Wrong time
? Wrong medication
? Other (specify): ____________________________________________________________________________________________________________________________________________________________
Responsible individual (if known): ________________________________________________
4. Identify potential obstacles that may hinder the implementation of the quality or safety measure.
Although the above-listed information is currently collected, it is reported in a mish-mash fashion that complicates the coding process and introduces yet more errors. Some nursing staff, though, may be reluctant to adopt the new reporting procedures due to longstanding routines and habits. In addition, the code of silence that prevails in many hospitals may discourage the identification of the individual responsible, even in those cases where it is apparent.
5. Identify those groups or leadership roles within the entity with whom you may need to collaborate.
Besides the directors of the hospital and quality assurance service, each medical center’s clinical nursing leaders and field advisory committee should also collaborate on implementing and administering the new incident reporting procedures for medication errors. In addition, organization-wide seminars for all nursing staff describing the new reporting procedures and providing the opportunity for questions and answers should also be conducted.
Conclusion
Achieving optimal clinical outcomes in hospital settings requires the elimination of any preventable sources of misadventure, including medication errors that account for an alarming number of patient injuries and deaths each year. Although medication errors can occur during any phase of the administration process, nurses are responsible for the majority of medication administration in hospitals, and it is therefore not surprising that they also account for the majority of errors. Nevertheless, nurses can and should take active steps to reduce the error rate to the maximum extent possible, and the expanded reporting procedures described herein represent an important step in that direction.




References
About XYZ. (2018). XYZ Health Care Organization. Retrieved from https://www.va.gov/health/ findcare.asp.
Bellum, P. (2018). New study shows quality improvement initiative working. XYZ Health Care Organization. Retrieved from https://www.va.gov/health/NewsFeatures/20110825a.asp.
Incident reporting. (2015). XYZ Health Care Organization. Retrieved from https://www.va.gov/ vdl/documents/financial_admin/incident_reporting/irum.doc.
Stoppler, M. C. & Marks, J. W. (2018) The most common medication errors. MedicineNet. Retrieved from https://www.medicinenet.com/drugs_the_most_common_ medication_errors/views.htm.
The origin of the XYZ motto. (2018). XYZ Health Care Organization. Retrieved from https://www.va.gov/opa/publications/celebrate/vamotto.pdf.