A health-related situation that would prompt a systems-level patient safety concern is when a nurse administers medication to a patient wrongly that does not meet health standards. Patient safety is a crucial consideration in healthcare practice that nurses strive to attain (Vaismoradi et al., 2020). A nurse is considered to have made an administration error when they fail to administer medication within health standards that pertain to the right patient, right medication, right dose, right time, and correct route. When medical intervention is administered right, it minimizes the progression of a disease; however, when administered wrongly, it can harm a patient in various ways. This paper seeks to discuss the concepts of medication administration errors.
2.0 Background Information about Medical Administration Errors
a) Data supporting the need for change
Efforts to minimize administration errors exist, like implementing new technologies and streamlining processes. Reviewing direct observation studies of medical errors in health facilities, researchers approximated 8% – 25% median rates during medicine administration. Intravenous administration had the maximum rate, with an approximated median rate of 48% – 53% (Sutherland et al., 2020). A considerable amount of administration errors are experienced in hospitalized children. This follows the complexity of weight-based pediatric dosing that entails doses based on weight and height calculations. The disparity in weight utilized for calculations can elevate dose errors. With this disparity, dose preparation is a complex aspect in pediatric populations, which elevates the likelihood of wrong dose administration.
Distributional epidemiology of administration errors reveals that most errors entail dose omissions and wrong time administration. In the United States of America, administration errors occur in 5% to 20% of absolute drug administration, which increases costs in the healthcare industry additional $380 million. These administration errors harm 1.5 million patients annually and have approximately 400,000 adverse effects.
b) National Patient Safety Standards about administration errors
The Joint Commission has a primary objective to encourage healthcare organizations around the globe to develop a foundation for quality healthcare and patient safety hence playing a significant role in fostering national patient safety standards about medical admission errors. The commission’s first goal is to enhance patient administration accuracy. This intent pertains to admission errors that can occur at any stage during diagnosis and treatment. The goal aims to identify the patient for whom the medical practice is intended and to match the practice to the patient. Newborn babies are prone to these errors following their inability to speak and possess distinguishable features (ELMeneza et al., 2020). This intent encourages the use of identifiers like identification numbers, mobile numbers, or other features. The goal is significant as it encourages nurses to utilize a minimum of two identifiers during medication administration and collect blood samples, label containers with blood specimens, and utilize distinct approaches to identify newborn patients. This helps to minimize the risk of administering a medical procedure to the wrong patient.
Another goal is to enhance communication between health practitioners. This helps to provide a nurse with the results and other patient information in time for the prompt treatment of the patient. This entails developing written procedures for managing medical procedures, implementing procedures for regulating patient information, and assessing the timeliness of reporting relevant diagnostic results. This helps minimize the likelihood of administering a medical procedure to the wrong patient. The third goal is the safety of handling medication which entails labeling medications and labeling containers so that there are easy to identify. This aids in reducing the risk of administering the wrong dosage of a drug to a patient.
3.0 Impact of administration error as a safety concern
a) Impact on the value of the patient and the hospital setting
Administration errors affect the value of patients and hospital setting in various ways. After a medical administration error, the patient’s family can file a lawsuit against the hospital setting. Following the law, hospitals can suffer additional costs as settlement costs. In addition, the event may degrade the reputation of the hospital. These errors affect the value of the patient with regard to morbidity, mortality, adverse drug events, extra financial costs, and length of stay in the hospital setting (Alqenae et al., 2020). Patients who fall victim to medical administration errors and live in developing countries experience disabilities at a higher rate than those who live in developed countries.
4.0 Evidence-based practice change recommendation addressing administration errors
Integrating evidence-based practices can help promote change when dealing with safety concerns. An example is the utilization of a barcode medication administration that aids in minimizing admission errors by utilizing barcodes to label patients and patient records by connecting the proper medication to the right patient digitally. A study of administration errors in a healthcare system utilizing understandable barcoding technology discovered a 41% reduction in errors and 51% potential adverse drug events reduced by 51% (Wondmieneh et al., 2020). Another recommendation is the integration of smart infusion pumps with Dose Error Reduction Software (DERS). A survey indicated that 88% of healthcare facilities in the US utilize the technology.
a) Principle of high reliability in organizations
The principles of high reliability in a healthcare organization include sensitivity, preoccupation with failure, reluctance to simplify, resilience, and deference to expertise. Sensitivity to operations entails that nurses’ integration of innovative pump and barcode technology is closer to healthcare practices and duties than the healthcare management in a healthcare organization hence they are suitable in recognizing opportunities for improvement and potential failure (Rodziewicz & Hipskind, 2020). The evidence-based practices entail that nurses are accountable for brainstorming ways in which integration of the practices might break down. Reluctance to simplify entails that nurses be apt to challenge their beliefs by continuously benchmarking data and other quantifications of health performance. Resilience entails that nurses expect uncertainties in their methods and improvise accordingly. This entails eliminating barriers and collaboration among nurses and other health practitioners. Defense to expertise entails that high-risk health situations and experience swift alteration of circumstance require that nurses assess and respond urgently to the situations.
b) Potential barriers to the integration of the evidence-based practices
The integration of these practices is countered with various barriers. A barrier with barcode medical administration is that nurses might experience blockades in the workflow integrated with the practice. An instance is when a patient’s armband is complicated to read or medication has not been labeled or may not be included in the system. Another barrier is the malfunctioning of the scanning equipment. The integration of smart infusion pumps may be countered with incomplete knowledge of operating the technology accurately. When nurses utilize other strategies to solve technological workflow blockages by the practices, they are prone to administration error.
c) Potential interventions to counter the barriers
An intervention to counter barriers associated with barcode medical administration is the insurance of barcodes by health facilities to minimize scanning issues and workflow blockage. In addition, hospitals should hire IT specialists to constantly audit the functionality of barcode scanners in the hospital to reduce redundancies. Another intervention is training nurses to accurately use smart infusion pumps to reduce admission errors arising from manipulation of the technology. Nurses should also be well equipped with traditional practices that ensure accuracy with medical administration when the technology breaks down.
d) Significance of shared decision-making during implementation
Shared decision-making ensures that nurses and other health practitioners are on the same page. This entails that nurses agree to implement evidence-based practices on medical procedures to ensure accuracy in medical administration. In addition, it enhances the collaboration of health practitioners in a hospital setting.
e) Evaluation of results of evidence-based practices
The performance and reliability of integrating medical barcode scanners and smart infusion pumps can be measured with the number of medication administration errors after implementation. This data can be compared against the number of medical errors before implementation to determine the effectiveness of the practices.
f) Impact of integration of evidence-based practices
A significant impact on the delivery model after integration is the reduction of medication administration errors. This is following the fact that nurses will be more likely to administer the proper medication, proper dosage, right time, and correct route of administration to the right patient. Another impact is the increase in costs arising from the procurement and maintenance of the technology. Another significant effect is the collaboration between nurses and other health practitioners during implementation.
Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug safety, 43, 517-537.
ELMeneza, S., Abd ELMoean, A. E. A., & Abd ELmoneem, N. (2020). Study of medical errors triggered by medical devices in the neonatal intensive care unit. Edelweiss Pediatric Journal, 1(1), 7-12.
Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls. Treasure Island (FL): StatPearls Publishing.
Sutherland, A., Canobbio, M., Clarke, J., Randall, M., Skelland, T., & Weston, E. (2020). Incidence and prevalence of intravenous medication errors in the UK: a systematic review. European Journal of Hospital Pharmacy, 27(1), 3–8.
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.
Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1), 1-9.