Enhancing Quality and Safety

Medication errors continue to be a major concern in healthcare organizations around the world. These errors can occur at any stage of the Medication process, from prescription to administration, and can have serious consequences for patients. In the United States, medication errors are a prevalent issue, with at least one fatality occurring each day and approximately 1.3 million individuals getting injured annually as a result (Jacobson, 2021). Recent studies suggest that medication errors could be the third most common cause of death in the country, trailing only heart disease and cancer (Hanna, 2019).

While healthcare professionals bear the primary responsibility for preventing medication errors, it is important to recognize that the problem is complex and involves multiple factors and stakeholders. These may include issues with communication, documentation, training, and technology, as well as patient factors such as health literacy and adherence to medication regimens. In order to address medication errors, a multi-faceted approach is required that involves collaboration among healthcare professionals, patients, and other stakeholders, as well as ongoing monitoring and evaluation to ensure that interventions are effective in improving patient safety.

Scenario for Medication Errors

A 45-year-old man was admitted to the hospital for chest pain and shortness of breath. He had a history of high blood pressure and high cholesterol. The initial diagnosis indicated that he had a blocked artery in his heart, and he was scheduled for an angioplasty procedure the next day. The patient was prescribed a combination of blood-thinning medication and painkillers to manage his symptoms. However, the nurse who administered the medication did not check the patient’s medical history properly and failed to notice that he was allergic to one of the medications. As a result, the patient suffered an allergic reaction that caused swelling of the throat and difficulty breathing. The medical staff immediately intervened and administered an antidote to counter the allergic reaction. The patient’s condition stabilized, but he was still at risk of complications due to the medication error. The incident was reported to the hospital administration, and an investigation was initiated to determine the cause of the error and prevent similar incidents from happening in the future.

Factors Leading to Patient Safety Risk

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

In the scenario presented, the patient suffered an allergic reaction due to a medication error, which could have led to severe complications if not immediately intervened. Several factors could have contributed to this medication error, including inadequate communication, lack of double-checking procedures, and insufficient training. The nurse who administered the medication did not check the patient’s medical history properly, which is a crucial step in ensuring patient safety. Additionally, the hospital may not have had a system in place to prevent medication errors, such as computerized order entry or barcoding.

Solutions Based on Evidence-based Best Practices

Healthcare providers prioritize ensuring patient safety as a primary goal. Utilizing evidence-based and best practice solutions can effectively decrease medication errors and enhance patient safety. One solution is the implementation of electronic medication administration records (eMARs) which can help reduce medication errors by providing real-time access to patient medication history and reducing the risk of misinterpretation of handwritten orders (Fuller, 2019). 

Medication reconciliation, which entails reviewing a patient’s current medication orders against their current medication regimen to identify and resolve any discrepancies, is another possible solution to prevent medication errors (Patel et al., 2019). This can help prevent adverse drug reactions and improve patient outcomes. Additionally, promoting patient education and engagement can help reduce medication errors and improve patient safety (Rodziewicz & Hipskind, 2020). This can be achieved through the use of patient portals, medication education resources, and clear communication between patients and healthcare professionals. Implementing these evidence-based solutions can help reduce costs associated with medication errors and improve patient safety in healthcare settings.

The Role of Nurses in Coordinate Care 

Effectively coordinating patient care is a critical responsibility of nurses in ensuring the safety of medication administration (RN, 2022). They can effectively address the risk of medication errors by adopting medication reconciliation processes, which include reviewing patients’ medication histories, verifying medication orders with physicians, and ensuring that patients receive the correct medication doses.

 In addition, nurses can educate patients and their families about their medications, including potential side effects and drug interactions, to prevent adverse drug events and reduce healthcare costs associated with additional treatments and extended hospital stays (Rodziewicz & Hipskind, 2020). To optimize patient care, nurses can collaborate with interdisciplinary teams comprising pharmacists and physicians to develop evidence-based medication administration protocols, promote adherence to medication administration standards, and ensure that patients receive the best care possible. Such measures not only help enhance patient safety and health outcomes but also reduce healthcare costs.

Care Coordination and Stakeholders

Effective coordination with multiple stakeholders is essential for nurses to promote safety and quality improvements in medication administration. The interdisciplinary healthcare team, including physicians, pharmacists, and other healthcare providers, is an essential stakeholder that nurses should collaborate with to develop evidence-based medication administration protocols, promote adherence to medication administration standards, and ensure optimal patient care (Walton et al., 2019).

In addition to healthcare providers, patients and their families are crucial stakeholders in medication administration (Kimberley, 2022). Nurses must educate them about their medications, including potential side effects and drug interactions, to help prevent adverse drug events and reduce healthcare costs. This education empowers patients and their families to actively participate in medication management and advocate for their care.

Hospital administrators and policymakers are also critical stakeholders that nurses should work closely with to prioritize patient safety and reduce medication errors (Kimberley, 2022). Nurses can collaborate with administrators and policymakers to develop and implement policies and procedures and secure funding to support ongoing education and training for medication administration.

Lastly, the nursing profession itself is an important stakeholder in driving quality and safety enhancements in medication administration. Nurses must continuously update their knowledge and skills, staying informed about evidence-based practice guidelines and regulations. Through ongoing education and training, nurses can provide high-quality care, promote patient safety, and drive improvements in medication administration across the healthcare system.

Conclusion

Nurses play a crucial role in driving quality and safety enhancements in medication administration by working collaboratively with multiple stakeholders. This collaborative approach can mitigate patient safety risks, reduce healthcare costs, and improve patient outcomes. Additionally, nurses can continuously update their knowledge and skills through ongoing education and training, enabling them to provide high-quality care and drive improvements in medication administration throughout the healthcare system.

References

Fuller, A. (2019). Electronic Medication Administration Records and Barcode Medication Administration to Support Safe Medication Practices in Long-term Care Facilities. ERA.

https://era.library.ualberta.ca/items/5f13a1b6-a1e2-4f13-8b1d-7ea531d24c42 

Hanna, B. (2019, September 27). Medical Errors are the Third-Leading Cause of Death in the US: Johns Hopkins University Study. Berkowitz Hanna.

https://berkowitzlawfirm.com/blog/medical-errors-are-the-third-leading-cause-of-death-in-the-us-johns-hopkins-university-study/ 

Jacobson, A. (2021, May 2). Medication errors statistics. The Checkup.

https://www.singlecare.com/blog/news/medication-errors-statistics/ 

Kimberley. (2022, August 13). Who are the Stakeholders in Healthcare? Swift Digital.

https://swiftdigital.com.au/blog/stakeholders-healthcare/ 

Patel, E., Pevnick, J. M., & Kennelty, K. A. (2019). Pharmacists and medication reconciliation: A review of recent literature. Integrated Pharmacy Research and Practice, Volume 8, 39–45.

https://doi.org/10.2147/iprp.s169727 

RN, B. W., BSN. (2022, September 6). How to Prevent Medication Errors in Nursing? The Nerdy Nurse.

https://thenerdynurse.com/how-to-prevent-medication-errors-in-nursing/ 

Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2022, May 1). Medical Error Reduction and Prevention. National Library of Medicine; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK499956/ 

Rodziewicz, T., & Hipskind, J. (2020). Medical Error Prevention.

http://www.saludinfantil.org/Postgrado_Pediatria/Pediatria_Integral/papers/Medical%20Error%20Prevention%20-%20StatPearls%20-%20NCBI%20Bookshelf.pdf 

Tariq, R. A., & Scherbak, Y. (2022, July 3). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK519065/ 

Walton, V., Hogden, A., Long, J. C., Johnson, J. K., & Greenfield, D. (2019). How do interprofessional healthcare teams perceive the benefits and challenges of interdisciplinary ward rounds. Journal of Multidisciplinary Healthcare, Volume 12(1), 1023–1032.

https://doi.org/10.2147/jmdh.s226330