Risks of Medication Errors for Patients and Staff

Barcode Scanning

In a large metropolitan hospital, there have been multiple instances where patients received incorrect medications due to barcode scanning errors. The barcode system is meant to help nurses make certain that the right patient receives the right medication at the right dose and time. However, it has been malfunctioning intermittently, raising the risk for potential medication errors.

Background

Over the past six months, there have been 15 reported instances of barcode scanning errors. In three of these cases, patients received the wrong medication, though no severe adverse reactions were reported. In the remaining cases, the error was caught in time by healthcare providers paying close attention.

The Joint Commission's National Patient Safety Goals include the accurate identification of patients and the safe use of medications (Gosselin et al., 2019). The barcode scanning system is a tool to help achieve these goals. A malfunctioning system risks compromising these standards and putting patients at risk. Therefore, it needs to be addressed.

Assessment

The impact of the safety concern affects patients, staff, and the organization as a whole. Patients are at risk of receiving the wrong medication, potential adverse reactions, prolonged hospital stays, or even death if the error is a major one (Sutton et al., 2020). As a result, staff morale may weaken, or staff may lose trust in the system, prompting them to seek workarounds or bypassing the system altogether. This could in turn increase the workload and stress levels of other healthcare providers. The hospital on the whole risks potential lawsuits, poorer patient satisfaction, and a tarnished reputation if the situation persists.

The safety concern reduces the value for patients as they may not receive safe and effective care. For the healthcare setting, the value diminishes due to potential financial losses from lawsuits and decreased patient trust.

Recommendation

Using evidence-based change, the hospital should implement a new, more reliable barcode scanning system that has been tested in similar healthcare settings and that has demonstrated fewer errors (Sutton et al., 2020).

The recommendation aligns with the principles of anticipating and preventing errors, rather than reacting to them. A high-reliability organization seeks to create systems that prevent errors from reaching the patient (Sutton et al., 2020).

However, potential barriers exist in the form of financial constraints and resistance to change. A new system may be costly to purchase and implement. Likewise, staff may be resistant to learning a new system, especially if they have adapted to the current one. Interventions to minimize barriers may include seeking grants or financial assistance for healthcare technology improvements, and giving training and support for staff during the transition, and putting emphasis on the benefits of the new system for patient safety.

Shared decision-making helps through the engagement of all stakeholders, including nurses, pharmacists, physicians, and IT professionals. This way the new system meets the needs of all users. Their input can be used to identify both potential issues and solutions. The way to measure outcomes is to monitor and compare the number of barcode scanning errors over a six-month period before and after the implementation of the new system.

The current care delivery model of the hospital is a team-based care model, where teams work together to provide patient care. The new barcode system would enhance the team-based care model by ensuring that all members of the team have accurate and timely information about medications. It would also foster trust among team members, knowing that the system supports safe medication administration.