Introduction
The Healthcare setting is associated with many events which significantly affect the provision of care. These events have influenced the creation of policies that regulate healthcare advancement and ensure patients’ safety. Regardless of these policies, healthcare settings have continued to witness increased adverse events, resulting in claims of malpractices leveled against healthcare institutions and staff. Medication errors are an example of an adverse event commonly seen in healthcare facilities. Medication errors can occur in various stages of the medication administration process, including prescribing, transcribing, dispensing, administering, and monitoring the effects of medication. The study by Marshall and McIntosh (2017) alludes that the main cause of hospital-related complications, lengthy hospital stays, and increased readmission is medical errors. This paper aims to analyze the near miss-situation of medication errors in healthcare.
Case Study
The adverse event I witnessed in the Healthcare setting was of an elderly patient who complained of pain and wanted to get medication to relieve these pains. This forced the attending physician to prescribe 25mg of oxycodone to the patient and order the caregiver to issue it out to the patient. According to the attending physician, the dosage of this medication was to be increased if the pain persisted (Butler, 2020). Notably, a caregiver was instructed to increase the dosage to 30mg if the pain reached 9-10 on the 10-point scale. The patient continued to receive the pain medication as indicated by the physician since he felt the pain daily for the next two weeks.
However, a nurse who had worked for many hours on a particular night gave 300g of oxycodone to the patient. This dosage was ten times compared to the dosage recommended. The patient died the next day after taking an excessive dosage. The night attending nurse confirmed that the medication was given to the patient, and this was the main cause of the patient’s untimely death. This adverse event’s breakdown will provide an analysis of different people roles in the incident.
Analysis
An example of medical errors is the sentinel event presented in the case above. This sentinel event is serious since healthcare facilities have been experiencing increased medication errors in past few years. The complexities of healthcare processes have been increased by multiple aspects of technology and this has resulted in many adverse events like the medication error mentioned in the case above (Butler, 2020). Notably, the decision by the attending physician to prescribe oxycodone as a painkiller for the patient was a far-fetched. This revealed how oxycodone is a dangerous drug when prescribed and administered wrongly. Maybe, the attending physician would consider such factors and consider prescribing the patient with a pain reliever that does not pose a considerable risk as oxycodone.
The reason provided for the adverse event presented above was that the shift change was not done well, especially as far as communication was concerned. Additionally, the shift report was written incoherently, and the nurse stated that she read clearly from the report to provide the patient with 300mg. In contrast, in truth, it was supposed to be 30mg of oxycodone. Whereas the nurse in the previous shift was also to blame for the issue that took place, it is also clear that the new nurse who was tired at the time did not take time to consider how large the dosage was, yet she had practiced nursing for a long time. Indeed, these many failures were unnecessary, and the hospital is also at fault because of overworking its staff, which led to such eventualities.
Implications of Adverse Events
The implications of the event presented were far-reaching. On the one hand, the patient’s family was inconsolable, especially after learning that their patient died from the hospital’s incompetence or lack thereof. They were incredibly affected because the patient was the patriarch of the family and was held dearly, which was a significant loss to them (Hewitt, Chreim & Forster, 2016). As such, they chose to sue the hospital for the malpractice that led to the death of the patient. The issue was also broadcast on the public media, which affected the hospital’s stand in society.
On the other hand, the legal suit caused the hospital to spend a tremendous amount of money in the legal battle, as well as compensation. Worst of all, the hospital’s reputation was affected significantly, and many patients in the community chose to keep away from the healthcare facility involving the revenue generation of the hospital. All these were because of a simple medication error that could have been avoided had the correct practices been followed.
Quality Improvement Technologies Evaluation
Particular quality improvement technologies should have been considered to ensure that the event did not take place. As indicated, the shift report was written down on pen and paper, meaning that the hospital was yet to be computerized. The inclusion of the computer network would help reduce communication barriers (Marshall & McIntosh, 2017). In the computers, the electronic medical records (EMR) and the computerized physician order entry (CPOE) would be used collaboratively in highlighting patient needs. Electronic medical records are computer software that holds all patient information in an electronic format.
The computerized physician order entry is a tool that enters any physician order in the EMR about particular patients. The utilization of these systems will help in data entry, communicating patient issues, as well as reducing medical errors in the healthcare process since they enhance efficiency and effectiveness (Bae, Rask & Becker, 2017). The introduction of these systems into the healthcare process is costly, and there is a need for the inclusion of substantial organizational resources towards setting up the systems. Additionally, the staff will need to undergo some training to be able to utilize the computer systems presented competently (Khanna & Yen, 2014). To increase the effectiveness of these, it is also essential to consider some strategies such as the two-step verification process that involves verifying a particular procedure from a colleague before giving it to the patient. Indeed, it is clear that the issue would have been bypassed if, for instance, the attending nurse verified the information and got a second opinion concerning the amount of dosage indicated.
Institutions
Integrated solutions such as such as barcode scanning systems have been integrated at the time of medication administration by other institutions. These solutions help to ensure that the right medication is given to the right patient at the right time. This solution has been found to be effective in reducing medication errors and improving patient safety.
Quality Improvement Metrics
Quality improvement metrics are essential in ensuring that the healthcare interventions, processes, and systems perform as required and within the confines provided by a particular state, regional, or national health agencies. Concerning the quality technological interventions presented, the specific quality improvement metrics will include, among others, staff to patient ratio retention, hospital readmission levels, medication errors perpetrated over time, as well as a staff-patient ratio (Joseph-Williams et al., 2017). The practicality of the EMR and CPOE systems were calibrated and provided critical information figures and percentages that the hospital aimed at meeting. Concerning the dashboard from the facility, it was clear that this was the 9th medical error issue reported in the last year. The metrics provide for an average of 5 cases, meaning that the healthcare facility was over 80% above the recommended industry practice.
Quality Improvement Initiative
To ensure the improvement in the quality of healthcare delivery for the case presented, it is necessary to institute and come up with a quality improvement initiative. A quality improvement initiative that would work is the Continuous Quality Improvement (CQI). It is a framework that involves creating an environment that ensures that quality in healthcare delivery is improved continually (Hewitt, Chreim & Forster, 2016). Specifically, it concerns the issues that are present, including interventions that have been put in place, and ensuring that there are practical steps that have been utilized towards increasing productivity and increase the confidence level of the staff involved.
The CQI has been applied to the EMR and CPOE systems in the past, to understand how it can improve the performance of the EMR towards enhancing healthcare by the National Learning Consortium (Joseph-Williams et al., 2017). The focus was on various aspects of process integration and development, such as planning, implementation, review, and evaluation. The findings indicated that the CPOE and EMR systems could enhance healthcare delivery, and it was essential for the healthcare facility to include the same in its systems to ensure the continuous improvement of healthcare processes are achieved.
Conclusion
In conclusion, the adverse event presented was preventable; however, the outcome was unwarranted and led to the loss of life for the people involved. It is essential to learn from an adverse event and utilize the quality improvement initiatives that have been proposed for future events. The inclusion of technologically enhanced interventions, including the CPOE and the use of EMR, will be critical towards finding solutions for the problem presented. Quality metrics have also been presented with dashboard data showed that it could enhance the issues identified. When such systems are included, healthcare delivery will be improved, and healthcare will be provided that will enhance healthcare quality and ensure patient satisfaction.
References
Bae, J., Rask, K. J., & Becker, E. R. (2018). The impact of electronic medical records on hospital-acquired adverse safety events: differential effects between single-source and multiple-source systems. American Journal of Medical Quality, 33(1), 72-80.
Butler, S. M. (2020). Adverse Events. Advanced Practice and Leadership in Radiology Nursing, 213-221.
Hewitt, T., Chreim, S., & Forster, A. (2016). Double checking: a second look. Journal of evaluation in clinical practice, 22(2), 267-274.
Joseph-Williams, N., Lloyd, A., Edwards, A., Stobbart, L., Tomson, D., Macphail, S., … & Thomson, R. (2017). Implementing shared decision making in the NHS: lessons from the MAGIC programme. Bmj, 357.
Khanna, R., & Yen, T. (2014). Computerized physician order entry: promise, perils, and experience. The Neurohospitalist, 4(1), 26-33.
Marshall, S., & McIntosh, C. (2017). Strategies for managing adverse events in healthcare simulations. Healthcare Simulation Education: Evidence, Theory and Practice, 152-157.
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