Explain factors leading to a specific patient-safety risk focusing on medication administration.
While working at XYZ Healthcare, one of the baccalaureate nurses administered a drug to the wrong patient at the beginning of his shift. The daytime nurse successfully handed over the change. However, there was a mix-up in patient files leading to the administration of the drug to the wrong patient. This medication administration error led to the patient’s death, and the hospital was sued for negligence afterward. The case is still active in court as the organization seeks an out-of-court settlement.
The error occurred due to various factors that could have been prevented. One of the primary factors that might have resulted in this error was burnout due to workload. Bell et al. (2023) report that 82% of medication errors occur because of tiredness among nurses. Another potential factor leading to the error was incorrect preparation. According to Tariq et al. (2018), incorrect preparation occurs when the nurse’s mind is engaged in other activities during the handover, leading them to miss some details about the client’s file. Besides, the error might have occurred because of distortions, a common cause of medication administration errors. Tariq et al. (2018) report that distortions may arise from misunderstood symbols, poor writing, improper translation, and abbreviation use. For instance, the handover nurse might have been in a hurry and poorly labeled the patient’s file, leading to the mix-up and the wrong file being used for the specific patient. As a result, distorted writing might have led to the error. Further, the handover nurse was highly inexperienced, with only a year’s experience in practice. Preventing these factors is fundamental in eradicating medication administration errors.
Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
The organization’s primary goal is to improve patient outcomes and minimize or eradicate medication errors, such as administering a drug to the wrong patient at the hospital. Medication errors are highly costly for hospitals, patients, and other stakeholders, while others can lead to death. They contribute to the high healthcare costs, including health insurance. As a result, eliminating medication administration errors has become one of the primary goals of healthcare organizations and governments. Quality improvement (QI) measures and safety improvement plans are operative solutions for reducing medical errors and sentinel events. One of the primary solutions is to instill professionalism among nurses. Nurses must execute their tasks professionally by reading drug labels and having regular training in administering medication (Salar et al., 2020). Significantly, nurses should observe the rules that require them to read the medication labels and confirm the intended patient at least twice before administering the drug.
While the organization has an error reporting system, it relies on the analog process. The organization should improve its Electronic Health Records (EHR) system to include error reporting and build a mobile application to help nurses confirm patient details and wards before administering medication. In their study, Vaidotas et al. (2019) reported 88 events per million opportunities within departments with the electronic medical record compared to 164 events per million opportunities within the units when using traditional medical records. EHR is associated with fewer medication errors. At the same time, Mutair et al. (2021) contend that an error reporting program should be implemented in the system to encourage nurses to report such errors for swift action. Again, the organization can apply the professional guidelines and best practices outlined by the Quality and Safety Education for Nurses (QSEN), including providing patient-centered, compassionate, and coordinated care, encouraging collaboration and teamwork, and adopting evidence-based practice (EBP) (2023). The nurses should use electronic data to ensure accurate drug administration and assess patient safety and progress.
Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
Since they comprise the biggest group of healthcare experts, nurses have a special responsibility to coordinate care in a manner that encourages patient safety. Care coordination can be attained by deploying fundamental strategies, including cognitive decentering, back-up behaviors, contingency planning, and collective decision-making (Russ-Jara et al., 2021). Cognitive decentering occurs when nurses assume the perspectives of another practitioner to build a mental picture of other providers’ mental models of the safety issues within the facility. It is fundamental in shaping their mental model of the circumstance and can influence their actions.
Besides, nurses can bring coordination through thorough communication with others, including contacting one another to provide solicited and unsolicited treatment recommendations and collaboratively make decisions on medical therapy (Russ-Jara et al., 2021). Nurses can contact their peers or individuals with specialized skills when there is internal discomfort or uncertainty. Collaborative decision-making encourages teamwork, a primary requirement in reducing medication errors. Finally, nurses can coordinate care by adhering to the patient-safety principles and other guidelines that control care delivery (Vaismoradi et al., 2020). Specifically, practice nurses must ensure they adhere to safety measures on the management of outlying venous catheters, care-based illness precautions, cardiac surveillance and monitoring, policies on medicine management, handover between patient wards, and hygienic requirements like hand cleaning and use of surgical gloves when handling patients (Vaismoradi et al., 2020).
Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
To enhance patient safety and eradicate medication administration errors, nurses must coordinate with various stakeholders, including their peers, physicians, the organization’s management, patients and their families, insurance firms, and pharmaceutical companies. According to Rodziewicz et al. (2018), patient safety and medication error reduction shared responsibilities, with all stakeholders responsible for ensuring patient safety. The authors maintain that the stakeholders include individual nurses, patients, society, nursing educators, researchers, administrators, government, and agencies like the legislature and regulators (Rodziewicz et al., 2018). Others are accrediting bodies and professional nurse and physician associations (Rodziewicz et al., 2018). Society and the government should address the nursing shortage to guarantee patient safety. Further, there is a need to provide sufficient patient information to ensure they understand their rights and give them the confidence to question physicians when their safety is compromised. Nursing educators should sufficiently prepare nurses for safety and competent care during school. The hospital must also ensure they hire nurses graduating with an accredited program by the American Association of Colleges of Nursing (AACN) and those who have passed the national licensing examination (NCLEX). Overall, there should be extensive communication between the nurses and the other stakeholders to ensure patients receive safe care.
References
Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16620
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., … & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046
Quality and Safety Education for Nurses (QSEN) Institute. (2023). QSEN Competencies. https://qsen.org/competencies/pre-licensure-ksas/
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2018). Medical error reduction and prevention. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Russ-Jara, A. L., Luckhurst, C. L., Dismore, R. A., Arthur, K. J., Ifeachor, A. P., Militello, L. G., … & Weiner, M. (2021). Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis. Journal of General Internal Medicine, 1-9. https://doi.org/10.1007/s11606-020-06386-w
Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK519065/
Vaidotas, M., Yokota, P. K. O., Negrini, N. M. M., Leiderman, D. B. D., Souza, V. P. D., Santos, O. F. P. D., & Wolosker, N. (2019). Medication errors in emergency departments: is electronic medical record an effective barrier? Einstein (São Paulo), 17. https://doi.org/10.31744/einstein_journal/2019GS4282
Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of environmental research and public health, 17(6), 2028. https://doi.org/10.3390/ijerph17062028
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