Medication errors are a major concern when it comes to patient safety. Medication errors have been ranked as the highest cause of preventable harm to the patient. Therefore, there is a need for healthcare providers to assess the cause of medication errors. Identifying the root cause of medication errors is significant in that one can develop an intervention that targets the error and improve the quality of the process. in addition, poor understanding of a problem leads to resource wastage due to the implementation of an ineffective intervention. Nurses play a significant role in ensuring that patients receive quality care. Therefore, they have a role in identifying factors that negatively affect the patient’s safety. Medication errors affect the patient, the healthcare provider, the facility, and the community. This assessment will involve analyzing the root of a medication error that took place at the hospital, applying evidence-based strategies to address the issue, developing an improvement plan, and identifying available resources that can aid in implementing the plan.
Analysis of the Root Cause
Mr. O.M was admitted to the facility for the management of diabetic foot. The patient is 72 years old. The patient also suffers from Alzheimer’s and hypertension. The nurse received the patient in the ward and was provided with a brief history which omitted the fact that the patient was hypertensive. During drug administration, the nurse does not administer antihypertensive to the patient. After some time, the patient rings the bell. When the nurse attends to him, he states that he is not feeling so good. The patient complained of blurred vision, lightheadedness, and palpitations. The nurse suspected that the patient was hypertensive. She then decided to check his blood pressure. The patient’s blood pressure was high. The nurse then decides to go through the patient’s information during his admission. The nurse finds that the patient’s caregiver had reported that he is hypertensive and has been on nifedipine. The nurse then confirmed that the drug had been written in the treatment sheet to the patient to rule out that she was the one who had not seen it. However, the drug was not on the list.
The nurse identified the issue. The physician and the nurse had a major role to play in the error. If the nurse suspected the patient was hypertensive, the patient might have suffered severe consequences. While admitting a patient, it is the physician’s role to ensure that all patient treatments are well-indicated. This helps prevent omission errors. In addition, as the nurse receives the patient, they should also obtain their history. Based on their history, they should ensure that the physician has prescribed medications to help address all the issues. In addition, they should ensure all the drugs are written in the treatment sheet. In addition, while handing over the patient, the nurse should provide all the relevant information.
The patient experienced the effects of high blood pressure. In addition, their compliance with medication was altered. Compliance is key in managing hypertension. Poor adherence leads to complications like aneurysm, stroke, heart failure, affects memory, and affects the arteries of the kidney. Poor control of hypertension will worsen the patient’s Alzheimer’s. The patient did not even remember that he was hypertensive due to his condition. Therefore, the nurse should ensure that these patients are well taken care of in such a situation.
After identifying the issue, the nurse’s first responsibility was to attend to the patient, which she did. The nurse then informed the physician who had prescribed the issue, and he updated the medication. However, the nurse did not report the incident because they feared losing their jobs. The facility’s policies are not friendly, and the healthcare providers rarely report medication errors due to effects like bullying from their colleagues and punishment attached to the issue. Therefore, the other healthcare providers did not get the opportunity to learn from the incident, and there is a likelihood that the same mistake can be repeated in the future. The nurse then talked to the patient about his diagnosis. She educated him about diabetes, hypertension, and Alzheimer’s. In patients who suffer from the cognitive condition, the healthcare providers must keep reminding them of their disease and its management. When the condition reaches advanced stages, the family should consider providing the patient with a caregiver. There were no environmental factors that contributed to the issue. The factors that contributed to the event were poor communication and poor documentation.
The population of senior citizens is predicted to rise. The population is at a higher risk of medication errors. The likelihood of getting chronic diseases will also increase in this population. Most of the population experiences multiple illnesses that put them at risk for polypharmacy and multiple therapies. Due to physiological changes, the kidney’s and liver’s functionality is weakened as one age. The breakdown and elimination of drugs are impacted by the loss of these organs’ functionality, which puts the population at risk of toxicity. Medication mistakes that are harming this population must be addressed. Errors with medication can have a variety of causes. The majority of medication errors have an impact on the prescription and administration of medication. Of the errors, 0.8% were fetal, and 62% were detrimental. Omission, incorrect dosage, administration of the incorrect medication, confusion between medications with similar names or packaging, and unreadable handwriting are some of the causes of pharmaceutical errors (Mulac et al., 2021).
In addition to poor communication, inadequate knowledge of geriatrics pharmacology is a major factor that causes medication errors in this population. The pharmacokinetics and pharmacodynamics of drugs in this group are affected by various factors, and it is essential that before medications are prescribed, the hepatic and renal functionality are evaluated. Other causes of errors are poor documentation, inadequate patient information, polypharmacy, omission of drugs, understaffing, and inadequate reporting of medication errors. The root cause of the incident involving O.M the root causes of the incident are omission, poor communication, and poor documentation.
Application of Evidence-Based Strategies
According to Müller et al., (2018) the use of SBAR communication toll can help reduce errors in communication. In many facilities, the handover of information is still mostly unstructured. Uneven team participation, a lack of consistent information content, and frequent distractions are variables that detrimental to safe handovers. The risk of information loss during the handover phase is great due to the high amount of variability involved. Appropriate use of the strategy helps eliminate communication gaps. During handing over, the nurses need to utilize the strategy to ensure that they update the other nurse on what is the condition of the patient, how the patient has been, what they have done to the patient, and what they expect the nurse to take over to do to the patient.
Improvement Plan with Evidence-Based and Best-Practice Strategies
One of the approaches can be used in developing policies that advocate for an interdisciplinary approach to care. This approach will help reduce medication errors significantly. According to Manias, (2018) it is an approach that can reduce more than one type of medication error. This is because, as the healthcare providers develop the plan of care, they will evaluate the indication of all drugs and possible adverse effects and implement strategies to reduce polypharmacy. In addition, it is easy to identify if there are errors in the prescribed dosage and even other prescription parameters. In addition, the healthcare providers will have their roles clearly stated, and each will ensure that they implement their roles. The goal is to improve collaboration among healthcare providers in the management of patients and reduce errors. Suppose the strategy had been used in the management of the patient. In that case, there is a possibility that the nurse would have identified that the doctor had not included nifedipine in the prescription before handing over the patent. The intervention will take a month to be impended. During this period, the stakeholders involved will be allowed to air their opinion o how the intervention should be implemented. The healthcare providers will be educated on the significance of the intervention. In addition, the healthcare providers will be exposed to activities that will help improve teamwork and ease the transition.
Existing Organizational Resources
For the intervention to be implemented effectively, there is a need to ensure that the required resources are available. For the training, there will be a need to get an individual who is well-versed in interpersonal collaboration. The facility will have to secure a venue for the training. The facility will need to identify the material which will be used for training. This will include ensuring that the venue has a socket that can be used to present the PowerPoint presentation and ensuring that the healthcare providers are given writing materials. The facility will also have to organize workshops and activities which will aid in team building.
The institution has healthcare providers skilled in geriatric nursing; these providers can be used to help educate the healthcare providers on the needs of the senior population and why interprofessional collaboration can be helpful in meeting their needs. In addition, the facility has a meeting hall that they use for their CMEs. The meeting hall can be used for training purposes.
Conclusion
For quality improvement, root cause analysis is essential. The nurses must make sure they recognize the problems that hinder patient care to prevent harm to the patient. To manage the issues, evidence-based solutions should be put forward. The nurses should be aware of the diverse health requirements that the various populations present. When implementing the strategy, it is crucial to ensure that the resources at hand are considered.
References
Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert opinion on drug safety, 17(3), 259-275. http://doi/full/10.1080/14740338.2018.1424830
Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy, 28(e1), e56-e61. http://dx.doi.org/10.1136/ejhpharm-2020-002298
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). A systematic review of the impact of the communication and patient hand-off tool SBAR on patient safety. BMJ open, 8(8), e022202. http://dx.doi.org/10.1136/bmjopen-2018-022202
write