Analyze a Current Health Care Problem or Issue
NHS FPX 4000 Assessment 4 Attempt 2 Analyzing a Current Health Care Problem or Issue
In this assessment, I will continue to explore the consequences of medication errors and delve into some possible solutions in order to prevent or at the very least minimize their occurrence. Medication errors are described by the National Coordinating Council for Medicine Error Reporting and Prevention as “any preventable incident that may cause or contribute to inappropriate medication usage or patient harm while the medication is within the control of the healthcare practitioner.” It is critical to explore different options and solutions in order to assist healthcare workers in preventing medication errors. Not only because medication errors can result in patient harm but also because the error typically falls on the nurse or health care professional who provided the medication.
Elements of the Problem/Issue
According to studies, a hospitalized patient is estimated to be subjected to at least one medication error per day. Up to 35% of these medication errors result in severe or life-threatening outcomes for the patient (Schmidt et al., 2017). Medication errors can occur, for example, if a healthcare professional is constantly being interrupted or has too many patients to care for safely. Two examples of common medication errors include; A healthcare professional giving a patient the wrong medication and a patient being given the wrong dose of something. Medication dosage and timing should be thoroughly evaluated by the health care interdisciplinary team as an incorrect dose can have significant consequences when given.
NHS FPX 4000 Assessment 4 Attempt 2 Analyzing a Current Health Care Problem or Issue
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The significance of high-alert medications must be addressed when discussing medication errors. Insulin, potassium chloride, antibiotics, and heparin are just a few examples of these high-alert and commonly used medications (Mancha et al.). According to studies, high-alert medications, often known as HAM, account for 27 -72% of all medication errors (Sodre Alves et al., 2020). These errors sometimes occur due to a lack of knowledge surrounding dosing and scheduling, confusion between doses and concentration of medications and even a lack of awareness of the different types of insulin or the storing of these medications (Mancha et al.). A lack of understanding surrounding the medications themselves frequently leads to medication errors when using high-alert medications. High-alert medications should be handled with extra care and attention in order to avoid mistakes that may cause serious harm or death.
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Analysis
I frequently prepare and administer high-alert medications in my role as a nurse, so it is critical for me to be knowledgeable regarding the process of administering these medications. These medications must be treated with the appropriate level of precaution and care, and any consequences resulting from improper administration must be taken seriously because they have the potential to be lethal. I need to make sure that in my role as a healthcare professional, I am always up-to-date with current policies and procedures surrounding the preparation and administration of all medications.
Ethical Implications of Medication Errors
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When discussing medication errors, one should also address the ethical implications of such. The focus of which should surround the four ethical principles of autonomy (right to self-determination), beneficence and nonmaleficence (do good and do no harm) and veracity (honesty/truthfulness) (Sorrell J.M.,2017). All medication errors must be disclosed not only to the physician but also the patient, because when the patient is in the know he or she is able to make the best possible decisions regarding their treatment and care. Research shows that nurses can be hesitant when it comes to reporting medication errors out of fear from consequences. However, patients have the right to know if an error was made. They deserve to have all of the information presented to them so that they can make the best decisions regarding their care going forward. Also, if the patient is aware of the error, he or she will be more likely to speak up and identify any pertinent symptoms.
The Patients’ Bill of Rights, which guarantees complete disclosure of all medical treatments, including medication errors, places a strong emphasis on disclosure and the right to know (Sorrell J.M., 2017). Although many medication errors are not fatal, they can still have a detrimental effect on the patient, the person who made the error, and the system as a whole. Beneficence and nonmaleficence are the ethical principles that direct healthcare professionals to do no harm (Sorrell J.M, 2017). It is important to inform patients about medication errors with the provider present in case any therapies need to be started right away.
Additionally, it is an ethical obligation to provide patients with accurate information so that they are able to make well-informed decisions regarding their care. Every institution should have clear and detailed policies for reporting medical errors in order to assist with this. Honesty is the very foundation of veracity. In order to build and maintain a trusting relationship
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with patients truthfulness is necessary. A patient given the information to make informed and appropriate medical decisions also relates to the principle of autonomy.
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NHS FPX 4000 Assessment 4 Attempt 2 Analyzing a Current Health Care Problem or Issue
Considering Options and Solutions
It is critical to consider a nurse’s patient assignment, workflow, the electronic medical record, and the storage of high-alert medications when considering potential strategies or solutions to reduce medication errors. All of these factors aid in identifying whether the problem stems from the system or from the prep and administration process. Common problems related to medication errors include inconsistent IV tubing setups and connections, unopened clamps during infusion, and a lack of understanding or knowledge of the electronic medical record’s verification process (Schmidt et al., 2017). Management also needs to continuously review and if necessary update the policies and procedures behind high-alert medication preparation and administration thus, ensuring patient safety.
Another option worth considering is to examine the standard process currently implemented by using the “three C’s”. The “Three C’s” stand for connection, clamps and confirming pump settings (Schmidt et al., 2017) Improving this process could include verbalizing the steps in order to confirm the steps are being taken. This process does not add any extra time to a medication pass and can assist in ensuring medications are being properly delivered to the patient. Altering the acknowledgement step in the electronic medical record is an additional option to think about. One nurse could confirm orders instead of two and in doing this, she or he would relieve the second nurse from having to contend with yet another interruption while attempting to prepare and administer his or her own med pass.
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Insulin and IV potassium chloride are two examples of commonly used, high-alert medications associated with many medication errors. Potassium vials should either be removed from care units and replaced with premixed potassium provided by the pharmacy, or IV potassium chloride should be placed in a specific locked section of the unit, to help prevent medication errors with these two medications (Mancha et al.). To prevent label confusion with insulin, it is important to reduce the number of hospital presentations (Mancha et al.).
Implementation for change must start with management collecting feedback from staff regarding the current medication administration process. This will help shine light on problem areas that need improvement. To ensure that employees are adequately trained on the policies and procedures underpinning the administration of high-alert medications, management can also help by offering monthly educational opportunities. Hospitals should look into streamlining EMR’s so that information is in a tidy, orderly, and accessible location. This could eliminate the need for nurses to recognize and confirm administration on three different screens. Additionally, a streamlined process could increase speed, efficacy and comprehension for new graduates and traveling nurses.
NHS FPX 4000 Assessment 4 Attempt 2 Analyzing a Current Health Care Problem or Issue
Conclusion
In conclusion, medication errors continue to be a problem in the medical world and have an impact on people of all ages, backgrounds, and diagnoses. Medication errors can have long-term repercussions or even be lethal. The impact that the process and system have on medication errors and patients is something that nurses, nurse supervisors, and hospital administrators must be cognizant of. Streamlining medical records, properly identifying and storing drugs, and
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altering the process for acknowledging and verifying high-alert medications are a few potential remedies to medication errors. Finally, It is important for all healthcare workers to give feedback on current policies and procedures and to participate in continued education.
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References
Mancha , L., Del Moral , R. S., & Rey, C. Preventing Medication Errors Regarding High Alert
Medications. https://doi.org/10.1136/ejhpharm-2019-eahpconf.550
Schmidt, K., Taylor, A., & Pearson, A. (2017). Reduction of Medication Errors. Journal of Nursing Care Quality, 32(2), 150–156. https://doi.org/10.1097/ncq.0000000000000217
Sodré Alves, B. M. C., de Andrade, T. N. G., Cerqueira Santos, S., Goes, A. S., Santos, A. D. S., Lyra Júnior, D. P. D., & de Oliveira Filho, A. D. (2020). Harm Prevalence Due to Medication Errors Involving High-Alert Medications: A Systematic Review. Journal of Patient Safety, 17(1), e1–e9. https://doi.org/10.1097/pts.0000000000000649
Sorrell, J. (2017). Ethics: Ethical Issues with Medical Errors: Shaping a Culture of Safety in Healthcare. OJIN: The Online Journal of Issues in Nursing, 22(2). https://doi.org/10.3912/ojin.vol22no02ethcol01
