Medication Error in Clinical Settings

Clinical Application Paper
Medication errors are a serious public health problem and they pose a serious threat to patient safety. Medication errors are costly from an economic, human, and social viewpoint since all patients are potentially vulnerable to these errors. It is estimated that in the United States more than 250,000 deaths per year are attributed to medication errors (Dirik, Samur, Seren Intepeler, & Hewison, 2019). Nurses work in a fast-paced healthcare environment which makes administering medication to be a high-risk nursing task. Medication errors can occur at any phase of medication from prescribing, dispensing, transcribing, administering, monitoring, and reporting. When a nurse makes a medication error they are emotionally traumatized since most of them beat themselves up for making such an error and this might undermine their self-esteem and confidence. Medication errors can be caused by any member of the healthcare team, but nurses account for the majority since nurses execute the majority of medical orders and they spend over 40% of their time in the hospital administering medicines (Tong et al., 2017). This paper aims to not only offer an overview of the problem within the clinical setting but to also use evidence-based research to identify solutions that can be used to improve the situation and reduce medication errors. A plan will be developed to address the problem of medication errors and methods of evaluation identified.
The Problem
In our clinical setting, there is a computerized provider order entry system used for specifying patient prescriptions and reducing transcription errors. In the past nurses had a problem trying to transcribe what the provider had written and this was the major cause of medication errors. However, with the installation of the system, it was expected the errors would be eliminated. Sadly, this was not the case. The current problem is mainly due to administration and medication mixing. When a nurse is attending to multiple patients and he or she has to administer medication to the patients at the same time, he or she will prefer to retrieve the drugs at the same time and make only a single round. This is a time-saving strategy and it reduces the time spent moving from the medicine cabinet to the ward and back for other drugs. The problem comes when the nurse fails to label the drugs especially medicines in syringes, basins, and cups. The nurse ends up mixing the medication and administers the wrong medication to a patient. This results in adverse drug events as the patient is likely to react to the drugs and this will worsen the patient's condition. For our clinical setting, the main reason nurses prefer to use this system when administering medication is there is a shortage of nurses. When understaffed, nurses will be overworked and they tend to look for ways they can increase their efficiency and reduce the time they spend moving up and down instead of attending to patients.
During the administration of intravenous medicines, there are many stages where an error might occur. In our case, most of the errors have been due to selection errors where the wrong drug is selected and reconstitution errors where the dosage is administered. Looking at the errors mentioned one would assume this would be easy to correct, but this is not the case. The administration of the wrong medication as mentioned earlier has to do with mixing up drugs since the nurse failed to properly label the drugs. Reconstitution errors are caused by the administration of the wrong drug doses. There are standard dosages that patients should be given and when this is not indicated in the prescription most nurses will assume, they are to use the normal dosage. However, there might be instances where a nurse is not familiar with a particular drug, and instructions are not given as to the correct administration or dilution of a drug. This would result in the patient getting a higher dosage concentration than would be expected.
Background & Literature Review
A culture of safety is defined as one where there is a shared commitment of employees and management towards ensuring the safety of the work environment. A safe culture is where everyone is committed to preventing, identifying, and mitigating medical errors (Cho, Heo, & Moon, 2016). It is the responsibility of everyone to create and maintain a culture of safety. Various nursing variables can compromise patient safety namely behavioral noncompliance, staffing, knowledge deficits, systems problems, and lack of positive reinforcement when near misses are reported. Safety culture should be looked at from all perspectives since interventions will differ based on the responsibilities and roles of the nurse. Nurses should not be left to shoulder the efforts of a safety culture. Every healthcare worker is responsible for ensuring and promoting a safety culture (Cho et al., 2016). Without a safety culture, nurses are likely to make medical errors that would have in other cases been avoided. A safety culture reinforces the nurses' work culture where a nurse will be alert and careful when administering drugs to patients.
In a safety culture, a balance has to be achieved between not blaming individuals for errors and not tolerating bad behavior. The focus should be on effective teamwork, where nurses and other healthcare workers can collaborate and interact with each other openly without looking down on one another. All workers should understand the goal of the healthcare facility is to offer high-quality care to patients and this can only be achieved through collaboration and teamwork. The pervasive culture of blame should be eliminated if the healthcare facility is to accomplish its goal of eliminating medication errors (Lee et al., 2019). With the blame culture, the focus was on trying to determine the person who was at fault for them to be disciplined. However, this resulted in hiding rather than reporting an error. In a safety culture, the emphasis is on accountability, honesty, excellence, mutual respect, and integrity (Kelly, Harrington, Matos, Turner, & Johnson, 2016; Lee et al., 2019). The non-punitive approach will result in medication errors being reported early when corrective action can be taken early. In a safety culture, the focus is on what went wrong and not on who caused the problem. With this approach, the focus is on rectifying the mistake and not punishing the individual who caused the error (Kelly et al., 2016). This results in an open workplace where employees are willing to admit their mistakes and corrective action is taken.
Project Plan
Having an already existing system, the current project would involve training of nurses and other healthcare workers on a culture of safety. In the initial stage, we anticipate resistance since people fear change. However, to overcome this we will demonstrate to the employees the advantages they will get with the implementation of the new culture change. Based on Lewin's change model this is the unfreezing step. There should be change champions identified who will communicate the reason for the change and using vital information showcase how the change will benefit all the stakeholders involved. The change should not be painted as beneficial to the organization alone, but the employees as well. The second stage would be the changing step. In this phase, the change would be implemented. In our case, this would involve training the employees on how they can reduce medication errors and strategies they can employ to ensure they administer the correct dosage or dilute the intravenous drug properly. Culture change is the most difficult thing to do in an organization, but with persistence and perseverance, it is possible. During the changing phase, nurses will be trained on how to translate prescriptions from the provider order entry system. Nurses should be encouraged to ask questions where they are uncertain of the dosage or where the dosage has not been specified. In case of a drug that a nurse is not familiar with he or she will be encouraged to ask assistance from other nurses or from the provider for them to get clarification. Also, in this phase, healthcare workers would be encouraged to report any medication errors and be made aware there will be no punitive measures taken against them for reporting the error themselves.
The last step in the Lewin model is refreezing. In this phase, the new culture is reinforced and solidified. The new changes now become the new norm and new employees will be trained based on this new culture. Being non-punitive will initially push nurses to report early on any medication errors and this will allow for corrective action to be taken before there are adverse drug effects. Therefore, the patient will be given corrective drugs and they will recover early. Patient care can also be improved since it is now a team effort and not merely the work of nurses. Medication errors will be reported and with a focus on what went wrong a change can be recommended to rectify the problem. This is far better than blaming a single individual and no action is taken to rectify the situation. The safety culture will necessitate the nurse to always label the drugs in the supplies area, which will reduce the chance of administering the wrong prescription. The collaboration will also eliminate the issue of double dosage or missing dosage. Nurses would be communicating and alerting the incoming nurse during a shift change of patients who have and those who have not received their drugs. This will ensure the incoming nurse is aware of the patients who need medication and they can administer the medicines when the time comes.
Method of Evaluation
The clinical project will be measured based on the number of medication errors taking place and comparing them to how many there were before the implementation of the project. Initially, the evaluation will be done daily to ensure compliance is maintained. Nurses will be monitored closely and there will be leaflets across the nursing rooms reminding the nurses to observe the new changes and to continue the collaboration. The safety culture will be reinforced across all departments within the organization. Measures will be the number of errors and types of errors that have occurred within a given day, week, or month. With these measures, it will be easy to identify what needs to be changed and the improvements needed. All areas of the organization will be monitored and evaluated especially areas that touch on patient care and patient safety. The strategy is to ensure medication errors are eliminated and the errors that were being made were rectified. Also, the project would monitor for other areas where medication errors might occur.
Conclusion
Reducing and eliminating medication errors is the best way of ensuring and improving patient safety. The proposed project will modify the culture of the organization and have a safety culture in place. With this culture in place the organization can improve the quality of care it offers to its patients. The strategies mentioned in the project will ensure the project is successful. Encouraging the nurses to report any errors and not have any punitive measure issued against them will push them to report any errors. However, with a culture of punishment, nurses will continue hiding their mistakes for fear of being punished. Therefore, changing the culture to focus on what went wrong instead of who caused the error will demonstrate to the nurses the organization's desire to rectify the problem and not to punish the employee.
References
Cho, S.-D., Heo, S.-E., & Moon, D. H. (2016). A convergence study on the hospital nurse's perception of patient safety culture and safety nursing activity. Journal of the Korea Convergence Society, 7(1), 125-136.
Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of clinical nursing, 28(5-6), 931-938.
Kelly, K., Harrington, L., Matos, P., Turner, B., & Johnson, C. (2016). Creating a culture of safety around bar-code medication administration: An evidence-based evaluation framework. JONA: The Journal of Nursing Administration, 46(1), 30-37.
Lee, S. E., Scott, L. D., Dahinten, V. S., Vincent, C., Lopez, K. D., & Park, C. G. (2019). Safety culture, patient safety, and quality of care outcomes: A literature review. Western journal of nursing research, 41(2), 279-304.
Tong, E. Y., Roman, C. P., Mitra, B., Yip, G. S., Gibbs, H., Newnham, H. H., . . . Dooley, M. J. (2017). Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Medical Journal of Australia, 206(1), 36-39.