NHS FPX 4000 Assignment 3 Analyzing a Current Health Care Problem or Issue

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Analyze a Current Health care Problem or issue 

NHS FPX 4000 Assignment 3 Attempt 1 Analyzing a Current Health Care Problem or Issue

Drug administration is an integral part of nursing. Medication errors can be pernicious to a patient’s health. Medicines are prescribed by the doctor and dispensed by the pharmacist but the responsibility of current administration rests with the nurse. Each nurse is responsible for their practice. The result of medication errors varies from mild to deadly. Medication errors have been an ongoing issue in all healthcare settings. Healthcare organizations should ensure and maintain effective measures to prevent medication errors. 

According to National Coordinating Council for Medication Error Prevention and Analysis (NCCMERP,2021), a medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a healthcare provider, patient or consumer”. Some of the factors associated with this cause are transcript errors, look -alike, sound -alike medication packages, and nurse- patient ratio. This assessment will expand upon mediation errors issue, analysis of the problem/issue, potential solutions for the problem, ethical considerations, and implementation of the solution. 

                     Elements of the Problem/Issue 

Medication errors can be detrimental to a patient’s health and they pose a serious threat to a patient’s safety. These errors can add significant harm or even death to patients. The data shows that in the United States more than 250,000 deaths per year are appertaining to medication errors (Dirik et.al, 2019). A medication error can increase the length of stay at the hospital and the cost of the treatment. 

NHS FPX 4000 Assignment 3 Attempt 1 Analyzing a Current Health Care Problem or Issue

Medication administration is a high-risk nursing task. Drug error can happen at any phase such as prescribing, dispensing, transcribing, and administering. A few factors that can contribute to this error can be high-risk medications, exhaustion and fatigue of healthcare workers, and look alike -sound alike medication. 

High risk medications can cause serious injury or even death when incorrectly used. These medications include heparin, insulin, and IV potassium chloride (Mancha, et.al, 2019). This journal analyzed the circumstances that could lead to high- risk medication errors by monitoring calls to the hospital pharmacy to clarify doses, routes of administration and so forth. Medication error with high risk medication often occurs due to a lack of knowledge of medication. Most of the healthcare settings, require two professional registered nurses to verify the order and medication before the drug administration. 

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Look like /Sound alike (LASA) medications are another factor contributing to medication error. Shao et.al (2018) reiterate in their journal the need for constant attention needed by healthcare professionals, medical industry and regulatory authorities to avoid look alike medication packages in the interest of medication safety. Medication error prevention requires clinical vigilance. For example, In a 2016 study, the US Food and Drug Administration (FDA)approved a name change for the Brintellix, an antidepressant to Trintellix after citing 55 reports of confusion with the blood thinner name Brilinta and 2 documented incidences of serious adverse events. 

Another element that could attribute to a medication error is the exhaustion and the fatigue of health care workers from overworking. COVID 19 pandemic contributed substantial modifications to nurses’ day to day work which includes redeployment to priority areas that were unfamiliar to many of the nurses, mandatory full-time work schedules, and overtime hours. Burnouts can negatively impact patient care. A high level of “burnout” is an indicator of a reduction in perceived patient safety among critical care nurses (Alma’ Mari, et.al, 2020). 

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The main goal of nurses is to provide excellent and quality care to all patients. Medication errors pose significant risks to patients as they can be sometimes fatal. To maintain a safe environment and to avoid medication errors it is important for all health care professionals starting from ordering physicians to transcribing pharmacists to the nurse administering medication to follow the safe medication practices. The prevalence of medication error in an emergency room is moderately high. These errors include wrong medication or overdose/underdose. The emergency room is busy in nature and always has a heavy workload with requires attention of multiple specialties, various disease conditions requiring high-alert medications, and patients of all ages from newborns to the elderly. These conditions make an emergency room more prone to making medication errors (Shitu, et.al., 2020). 

I worked as an emergency room nurse a few years back and during that time I have prepared and administered high alert medication most of my shifts.  As a nurse, it is crucial to pay attention to what medication is being ordered for the patient, what medications need to be pulled out from the medication pyxis, and how to administer the medication. Strictly maintaining and following the five rights of mediation administration can widely prevent medication error to a greater extent. Adhering to the five rights of medication administration does not mean you won’t have any medication errors but it can decrease the chances of having one occur (Manouchehr, 2020). 

                 Considering Options and Solution 

Interventions have been developed and implemented to reduce drug errors in all healthcare settings. There are many ways to improve medication safety. When considering options to reduce medication errors, it is necessary to look at the nurses’ competency, storage of high alert medications, and electronic medical records like computerized physician order entry (CPOE). 

Nursing staff needs more education and up- to- date training. This can be done by conducting annual workshops for nurses in their clinical settings, and organizing seminars to improve their understanding of new topics. Also, consider getting suggestions from the nurses who have made medication errors. This will help to identify the factors for the error and helps to identify a solution to resolve the error. Verifying high -risk medication with another professional registered nurse is another option to minimize medication error. Each organization can develop protocols regarding the double verification requirement. High- risk medications should be stored from other regular medications. For instance, if the pharmacy removes potassium vials from regular medication pyxis and instead provides premix potassium chloride bags will be another option to reduce medication error. 

Computerized Physician Order (CPOE) is another proposed solution to overcome medication errors (Elshayib, et.al., 2020). This helps clinicians to place medication and other therapy orders electronically with the assistance of pre-determined rules, alerts and knowledge databases. The handwritten orders by physicians can confuse in writing whereas in CPOE that confusion can be eliminated since the orders are entered electronically. CPOE results in more legible, structured and complete prescriptions. Therefore, data shows an improvement in the communication between nurses, physicians and pharmacists when compared with handwritten orders (Sotoca, et.al.,2018)

At the same time, CPOE itself could become the source of errors mainly due to the inexperience of using the program. Experts point out that CPOE is not just the implementation of information technology rather it is a major organizational process change. Implementation of this data entry can alter the current communication pattern, and workflow and create more work.  Therefore, the readiness of the organization and preparedness to adopt a new intervention needs to be considered before the implementation (Elshayib, et.al.,2020). 

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NHS FPX 4000 Assignment 3 Attempt 1 Analyzing a Current Health Care Problem or Issue

            Ethical Implications and Implementation 

Successful implementation of a proposed solution such as computerized physician order entry (CPOE) is a challenging process for any healthcare organization. This requires a multidisciplinary team approach for the best outcome. In these cases, health care organizations might face an ethical dilemma at some stages. To best navigate these challenges, health care organizations need to follow four fundamentals of ethics-autonomy, beneficence, non-maleficence, and justice. 

Autonomy refers to the right to decide for themselves. CPOE enables providers to issue orders electronically. The COPE implementation will provide access to support providers and other clinicians in the ordering process and thus improve patient safety and quality of care. Not everyone is computer savvy.  Therefore, besides computer -related literacy, exploring end- user attitudes and expectations will help to understand the factors that influence adherence to new technology in health care (Nymberg, et.al.,2019). This can be assessed during clinical workshops and monthly meetings or by doing surveys.  

Beneficence and non-maleficence are closely related. These are often described as “Do what is best for the patient “or “Do not harm”.  The implementation of CPOE has reduced the rate of potential medication errors. This implementation supports coordination of clinical tasks among patient care teams, reduction of misinterpretation of orders, minimization of illegible orders, assistance with medication dosage calculations, and decision support using alerts like drug-drug interactions, drug allergy, and dosage suggestions (Abraham, et.al.,2018). Creating policies and protocols for verifying high alert medication is another implementation that the administration should place to avoid medication errors.  

Justice, the fourth ethical principle, means giving fair, equitable and appropriate treatment to each individual. Patient safety should be the topmost priority in the health care setting. Implementation of the CPOE system in the health care system provides appropriate treatment to patients because of its various safety levels with basic information to facilitate prescription such as maximum dose, predefined regimens, duplication, length of treatment, drug interactions, etc. 


In conclusion, a medication error is a prevalent issue in the healthcare system and it impacts patients of all ages irrespective of their diagnosis and age. Reading and analyzing multiple peer- reviewed articles and journals provided me with factual and credible supportive statements for this research paper. Some factors that contribute to medication errors are a transcription error, look alike, and sound alike medication. A potential solution to resolve this issue includes nurse continuation education, verification of high alert mediation with another registered nurse, and introduction of standardized order entry such as CPOE. Successful implementation of these potential solutions would likely improve patient safety in regard to medication error. 


Abraham, J., Kannampallil, T. G., Jarman, A., Sharma, S., Rash, C., Schiff, G., & Galanter, W. (2017). Reasons for computerized provider Order Entry (CPOE)-based inpatient medication ordering errors: An observational study of voided orders. BMJ Quality & Safety, 27(4), 299–307. https://doi.org/10.1136/bmjqs-2017-006606 

AL Ma’mari, Q., Sharour, L. A., & Al Omari, O. (2020). Fatigue, Burnout, work environment, workload and perceived patient safety culture among critical care nurses. British Journal of Nursing, 29(1), 28–34. https://doi.org/10.12968/bjon.2020.29.1.28 

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. https://doi.org/10.1111/jocn.14716 

Elshayib, M., & Pawola, L. (2020). Computerized provider order entry–related medication errors among hospitalized patients: An integrative review. Health Informatics Journal, 26(4), 2834–2859. https://doi.org/10.1177/1460458220941750 

FDA Drug Safety Communication: FDA approves brand name change for … (n.d.). Retrieved April 28, 2022, from https://www.fda.gov/media/97536/download 

López Mancha, M. T., Sánchez del Moral, R., Contreras Rey, M. B., Rodriguez Molins, E., Romero Alonso, M. M., & Estaire Gutiérrez, J. (2019). 5PSQ-117 preventing medication errors regarding high-alert medication. Section 5: Patient Safety and Quality Assurance. https://doi.org/10.1136/ejhpharm-2019-eahpconf.550 

Manouchehr Saljoughian, P. D. (2020, June 18). Avoiding medication errors. U.S. Pharmacist – The Leading Journal in Pharmacy. Retrieved April 28, 2022, from https://www.uspharmacist.com/article/avoiding-medication-errors 

Nymberg, V. M., Bolmsjö, B. B., Wolff, M., Calling, S., Gerward, S., & Sandberg, M. (2019). ‘having to learn this so late in our lives…’ Swedish elderly patients’ beliefs, experiences, attitudes and expectations of e-health in primary health care. Scandinavian Journal of Primary Health Care, 37(1), 41–52. https://doi.org/10.1080/02813432.2019.1570612 

NHS FPX 4000 Assignment 3 Attempt 1 Analyzing a Current Health Care Problem or Issue

 NCC MERP . About medication errors. Retrieved April 21, 2022, from https://www.nccmerp.org/about-medication-errors 

Shao, S.-C., Lai, E. C.-C., Owang, K. L., Chen, H.-Y., & Chan, Y.-Y. (2018). Look-alike medication packages and patient safety. Journal of Patient Safety, 14(3). https://doi.org/10.1097/pts.0000000000000506 

Shitu, Z., Aung, M. M., Tuan Kamauzaman, T. H., & Ab Rahman, A. F. (2020). Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4921-4 

Sotoca, M. G., Saavedra, F. J. P., Castro, B. M., Sogues, M. M., Valero, L. V., & Arnaiz, J. A. S. (2018). 5PSQ-115 computerized physician order entry impact on medication errors in a pediatric unit. Section 5: Patient Safety and Quality Assurance. https://doi.org/10.1136/ejhpharm-2018-eahpconf.468