Exploration of Regulations and Implications for Practice
NURS FPX 6410 Exploration of Regulations and Implications for Practice
Medical error account for ten percent of all U.S. deaths. Per a study at Johns Hopskins, their patient safety quantified that more than 250,000 deaths per year are due to medical error. This information was published in 2016 in the BMJ, which contradicted the Center for Disease Control’s third leading caused of death being respiratory disease. The team at Johns Hopkins infacticly states that the CDC’s way of gathering national health statistics fail to rank medical errors separately on the death certificate. Advocation by researchers for this update is ongoing. (Daniel, 2016).
One of the most common issues affecting the health care industry are medical errors. These errors have the potential to be non-life threatening, minor, or fatal. These errors are costly to the hospital due to loss suits and it being a cloud of distrust to the patient.
Kaiser Permanente has collaboration with all disciplines (stakeholders) to develop a system for administration of higher risk medications that could be fatal if given in the wrong dosage. This system is called High Alert Medication. It was determined that more than half million doses of HAM were administered, per data collection review process. (Clopp.etal, 2008). Although this process was first rolled out in Northern California’s Kaiser Permanente in 2005, it has since been rolled out as best practice to reduce the errors connected to High Alert Medication within all Kaiser Permanente clinics, hospitals, and at other medical facilities nation wide.
Most facilities nationwide have implemented similar protocols to prevent nursing errors related to medication errors but also unnecessary delays in treatment, incorrect documentation, mistaken identity, under-treatment, preventable falls and infections along with wrong patient wrong surgery (Katuka, 2018). Example, Scheduled left arm amputation, but right arm amputated.
Information Model and Safe Practice
By applying the foundation of nursing model, nursing informatics can help mitigate the risk of errors in healthcare by support in training staff, process improvement and making sure to use best practice guidelines to decrease patient danger and improve the overall quality of care. Everyday, subconsciously nurses utilize technology as a source of data collection in regards to their regular daily workflow. This could also vary depending on the size of the organization. Regardless of the size of the organization, healthcare facility or system, ( For example: University of California.), incorporating the Technology Informatics Guiding Education Reform (TIGER) initiative with informatics would be useful to educate staff on current technological practices and reinforcing that this would improve nursing practice (Calderon & Hedba, 2010).
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The priority of all healthcare organizations is safe practice. The healthcare system for a patient’s is where for most life begins and for others where it ends. The task of safe medication administration revolves around the procedure of Electronic Medication Management (EMM). It begins with the doctors order, the review of those orders by the pharmacist, then verifying any contraindications through the automated system, depending on the form of medication, calculating the dosage right and some medications also require an independent double check by an RN. Before administering the medication, the RN has to perform the 5 rights. Right patient, right time, right dosage, right medication and right route. This is very important in safe practice in regards to medication administration. These steps can also help decrease medication errors. The automated dispensing cabinets, (ADC), and barcode medication administration also play an efficient role in medication management. The closed loop electronic system for medication management can curb human errors if applied correctly. (Pearce & Whyte, 2018)
Making the job of medication administration less intricate through the use of ADC’s and BCMA along with proper training of these devices should reduce possible medication errors. Banding patients with coded wristbands and bedside computers with scanners have also been beneficial in reducing medical errors.
Goal
The goal is to have a decrease in medical error, patient deaths due to medical error and other abnormal patient outcomes due to medical error. Using hospital admission rates from 2013, that was based on a study totaling the hospitalizations of 35,416,200, 25145 deaths were caused by medical error. This translates to 9.5% of all deaths in the USA each year. (Makes, 2016).
Outcomes
As it stands, despite all the technologies, safety measures in place and standards of practices use, the total of deaths in the USA from medical errors has not changed significantly. The three common types of malpractice was caused by diagnosis failure, birth injury and treatment failure. These are also forms of medical errors. In most recent years these numbers have also risen.
Ethical Consideration
Nursing Informatics is a required facet of healthcare that can infringe on the ethical and legal components of the care process. Nurses must operate within the Code of Ethics. This means being committed to protect the rights, health and safety of the patient choosing accountability and responsibility to nursing practice, make good decision and always promote health and provide optimal health care. In the role of a nurse, one must take the Code of Ethics as law for nursing practice. Most organizations state that they have what is called, “just culture”. What that is supposed to mean is the staff feels safe, comfortable and free from retaliation if a medication error, near miss or possessing the knowledge that another nurse made an error. In reality things are different. Patient safety is the primary goal at all healthcare organization. No one (nurses, doctors, pharmacist etc.) is perfect and without the possibility of human error.
NURS FPX 6410 Exploration of Regulations and Implications for Practice
Stakeholders
The major stakeholder when a medical error happens, be it fatal or not is the organization and the collaboration team, (nurse, RT, doctor etc.) involved and the patient it occurred to. The standards for patient safety applies to all employees involved along with the outcomes of the error. Near misses, and errors should be easily documented. The tracking mechanism must be available and accessible so that the root cause can be discovered and future errors can be prevented.
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Standards Of Practice
Standards of practice are critical tools that add to and guarantees that the healthcare organizations are developed to meet mandated standards. Evidence based standards of practice will make certain that the healthcare process accomplish the intended reason in the best way. These standards of nursing should be demonstrated each and every time a nurse comes in contact with the patient. This should begin at the initial head to toe assessment all the way to documentation process, and at the final stage of discharge. Documentation, communication and distractions are just a few of the reasons that medical errors occur. The various forms of improper or miscommunication that occurs in a medical error, improper communication either verbally or written and misinformation or crucial facts not being stated or understood clearly. (Calderone & Hedba, 2010). There are different forms of technology that nurses use on a daily basis when charting vitals, assessments, progress notes, critical notifications, signing setting up and signing off on IV pumps for antibiotics, double check IV medications etc. The use of theses various forms of technology should be used to demonstrate one’s skill set and knowledge for a positive outcome for the patient. To keep patients in good health or to improve their health, knowledge, skill, and attitude technology must be used efficiently.
NURS FPX 6410 Exploration of Regulations and Implications for Practice
Regulatory Consideration
In the year 2000, the Institute of Medicine’s report To ERR is Human. In 2000, which set in motion for the focus to be on patient safety in healthcare. The national report for healthcare quality and safety is Crossing the Quality Chasm. Organizations have created initiatives such as the Agency for Healthcare Research and Quality for Safety Research, (AHQR), the Joint Commission Patient Safety Goals, the Office of National Coordinator for Health Information Technology (HIT) to modernize health care with EMR, and the World Health Organization’s Alliance for Patient Safety. With the help of Congress, a bill was passed to promote no blame reporting of incidence culture and participate in the learning process. The bill is the Patient Safety and Quality Improvement Act. (McGonigle & Mastrian, 2018). All of these organizations and initiatives were designed to help safe-guard patients from hurt, harm or death from accidental medical errors.
Conclusion
Nurses are the last line of defense most of the time, in preventing a medication error. The reason being because they are the ones who administer the medication that the doctor ordered and the pharmacy provided. That’s why it is important for nurses to know the organizations policies and procedures in regards to medication administration and follow them accordingly. Protocols are provided to put in place the best practice standards and exist to provide consistency and uniformity across the board. Failure to go along with the rules of the organization can possibly endanger the life of the patient but also expose the organization and the nurse to a lawsuit.
References
Calderone, T., & Hebda, T. (2010). What nurse educators need to know about TIGER
initiative. Nurse educator. Http://pubmed.ncbi.not.nih.gov/20173588/.
Clopp, M.P., Crawford, B., Graham, S., & Kostek, N.E. (2008). Implementation of a high alert
medication program. The Permanente Journal.
NURS FPX 6410 Exploration of Regulations and Implications for Practice
Daniel, M., (2016). Study Suggests Medical Errors Now Third Leading Cause of Death in the
U.S. John Hopkins Medicine.
Katulka, L. (2018). The 8 most common nursing mistakes: Berxi
http://www.berxi.com/resources/article/most-common-nurse-mistakes.
McGonigle, D., & Mastrian, K.G. (2018). Nursing informatics and the foundation of knowledge.
Pearce, R., & Whyte, I. (2018). Electronic medication management: is it a silver bullet?
Australian prescriber, https/www.ncbi.nominated.nhi.gov/pic/articles/PMC5895475/.
