In my nursing practice, I have observed the recurring problem of Medication Administration Errors (MAEs). MAEs refer to any discrepancy between what the patient received or was supposed to receive and the prescriber’s original order. These errors have had negative impacts on our patients, including increased morbidity, mortality, adverse drug events, and extended hospital stays.
After discussing the issue with our Nursing Director, it became apparent that our hospital’s approach to addressing MAEs needed improvement, particularly in terms of reporting and measuring them. Currently, our facility relies on incident reports for documenting MAEs. However, this method is voluntary, and many nurses may hesitate to fill out the report due to fear of consequences or concerns about self-reporting. Consequently, the incident report system does not capture all instances of MAEs accurately.
NURS 4220 WEEK 2 PRACTICUM DISCUSSION: Applying Measurement Tools to a Practice Problem
When interviewing our Quality Improvement (QI) Manager, it was revealed that the QI department rarely receives notification forms from nurses regarding MAEs. This raises questions about why nurses have become complacent in reporting their colleagues who commit MAEs.
While incident reporting is a widely accepted method in healthcare facilities for identifying and learning from errors, there is a need for alternative approaches to strengthen the incident report system. Other methods, such as chart review and direct observations, can be employed to gather more comprehensive data on MAEs. These additional measurement tools would enhance the accuracy of reporting and enable better analysis of the prevalence and causes of MAEs.
NURS 4220 WEEK 2 PRACTICUM DISCUSSION: Applying Measurement Tools to a Practice Problem
To address the issue effectively, it was agreed upon by the Nursing Director and the QI Manager that certain measures should be taken. These include providing comprehensive training for nurses, improving job security, ensuring management support, hiring more nursing staff, and reviewing medication administration processes. By adopting these strategies, medication errors can be reduced, and nurses’ willingness to report such errors can be increased.
In conclusion, the problem of MAEs requires a multifaceted approach that involves improving reporting and measurement systems, enhancing training and support for nurses, and implementing changes in medication administration processes. By incorporating alternative measurement tools and addressing underlying concerns, we can accurately measure and mitigate the occurrence of MAEs, ultimately improving patient safety.
References:
Feleke, S. A., Mulatu, M. A., & Yesmaw, Y. S. (2015). Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC nursing, 14, 53.
Härkänen, M., Saano, S., & Vehviläinen-Julkunen, K. (2017). Using incident reports to inform the prevention of medication administration errors. Journal of clinical nursing, 26(21-22), 3486–3499. Mostafaei, D., Barati Marnani, A., Mosavi Esfahani, H., Estebsari, F., Shahzaidi, S., Jamshidi, E., & Aghamiri, S. S. (2014). Medication errors of nurses and factors in refusal to report medication errors among nurses in a teaching medical center of Iran in 2012. Iranian Red Crescent medical journal, 16(10), e16600.
Pitkänen, A., Teuho, S., Uusitalo, M., & Kaunonen, M. (2016). Improving medication safety based on reports in computerized patient safety systems. CIN: Computers, Informatics, Nursing, 34(3), 122-127.
Stavropoulou, C., Doherty, C., & Tosey, P. (2015). How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. Milbank Quarterly, 93(4), 826–866.
