NHS_FPX4000 Analysis of Medication Errors Paper
An Analysis of Medication Errors
The current technological advancements and increased patient knowledge enhanced by increased access to information from the internet and other sources imply that the demand for patient safety and quality of care service has only increased. However, various events or situations in the patient care environment still exist that threaten patient safety and the quality of patient service. As highlighted in the previous assessment, medication errors fall under this category due to the vast adverse impacts it has on patients, healthcare professionals, and the hospital or healthcare facilities where such errors occur. Indeed, medication errors threaten patient safety, which has been considered the fundamental care quality dimension (Mieiro et al., 2019). As such, the purpose of the latest assessment is to explore the clinical problem of medication errors further. Therefore, various aspects will be explored including, the description of the problem, an analysis of the health care problem, the potential solutions for the problem, and an explanation of the ethical principles if the proposed solution is not implemented.
The Elements of the Clinical Problem
Medication errors have largely been referred to as any preventable event that can lead to or cause an inappropriate use of medication or patient harm while the medication is the control of the consumer, patient, or healthcare professional. The implication is that a medication error occurs when there is a failure in the treatment process leading to or having a potential of leading to harm to the patient (Gates et al., 2019). Medication errors can occur in various ways. One of the forms is prescription errors. Prescription errors occur while choosing a medicine, where the authorized healthcare professional over-prescribes, under-prescribes, ineffectively prescribes, inappropriately prescribes, or where there is an irrational prescription.
Medication errors can also occur when a contraindicated medication is used, incorrect treatment duration, incorrect dispensing, mislabelling, giving medication to a wrong patient, omission errors, unauthorized medication, incorrect route, expired medication, incorrect medication preparation, and using an incorrect medicine (Nguyen et al., 2018). It is worth noting that while there are various types of medication errors, most of the medication errors occur at the prescription or ordering stage, for example, a healthcare professional writing a wrong frequency, wrong dose or route, or wrong medication. Indeed, these errors have been shown to account for close to half of all the medication errors that occur in a facility. In addition, up to seventy percent of medication-ordering errors are identified by pharmacists and nurses.
The Analysis of the Problem
As earlier indicated, medication errors form part of the most common problems impacting negatively on patient care and the patient care effort. A medication error is considered as any preventable event that can lead to or cause an inappropriate use of medication or patient harm while the medication is the control of the consumer, patient, or healthcare professional. Medication errors also form part of the problems that mostly lead to patient mortality and morbidity. This is shown by the fact that medication errors are responsible for up to seven thousand deaths annually (Mieiro et al., 2019). Therefore, it is conceivable that efforts should be made to help find better strategies for dealing with the issue.
The Problem’s Context
Medication errors can occur in any department of the hospital where patient care is offered. As such, there are various causes of medication errors in these care settings. A pharmacist can cause a mechanical or judgmental error. While mechanical error occurs due to prescription or dispensing mistakes, the judgemental error occurs due to inappropriate monitoring, failure to offer the patient counsel, inappropriate screening, and failing to detect the possible interactions. Distractions have also been shown to heavily contribute to medication errors, as close to three-quarters of all the medication errors are caused by distractions (Nguyen et al., 2018). Various distractions such as talking on the phone while prescribing or dispensing, talking to someone or when rushing to write an order all may lead to distractions leading to various kinds of medication errors.
Distortions can also lead to medications errors, and it is one of the most prevalent causes of medication errors. Such distortions arise due to improper translation, the use of abbreviations, misunderstood symbols, and poor writing. When a physician prescribes a medication that may not be in stock at the facility, the pharmacist or nurses may seek to substitute the prescription, which may lead to further errors (Nguyen et al., 2018). Illegible writing is another cause of medication errors; when physicians scribble down orders and they are not visible, the major mistakes can occur, leading to unwanted patient harm. When a hospital employee commits a medication error, then various reasons can be implicated. Some of the reasons that have been found include carelessness, an act of vengeance, poor motivation, hurrying, forgetting, and negligence.
Why the Problem is Important
Problems usually need solutions if the people impacted by the problem must have better outcomes and life. Central to formulating a solution is knowing why the problem is important. First, the problem is important since it is largely preventable through various strategies, yet the problem remains prevalent. Again, medication errors have various adverse effects on the patient; therefore, as an individual who believes that patients should have the best, I believe that efforts should be made to ensure that the patients have better outcomes.Medication errors cost billions of money alongside the fact that they lead to enhanced rates of mortality and morbidity among the patients affected (Billstein-Leber et al., 2018). Again, medication errors also lead to other adverse effects such as increased length of hospital stay, which may expose a patient to various infections.
The problem of medication errors affects various people and entities. One of the individuals who face the problem mostly is the patients. The patient uses these medications and therefore is affected the most if such a medication error were to occur. The other people impacted by medication errors are the healthcare professionals such as nurses. It is key to note that when a professional such as a nurse is involved in a medication error, such a nurse is under the risk of disciplinary procedure within the organization (Billstein-Leber et al., 2018). The nurses can also face a legal proceeding if the client decides to sue the nurse and feels that the medication error was largely due to negligence or ignorance. The problem of medication errors also affects the institutions where the error occurs. With the increased technological advancements in the form of social websites such as Facebook, information can spread quickly, so a patient who feels something was not right with the medication can easily use a hashtag to spread the word fast about how bad the facility is hence leading to negative publicity.
The many adverse impacts of medication errors mean that a lot of interest has been shown in trying to find the most suitable solutions. The problem of medication errors can be solved using various approaches. One of the approaches is the use of technologies like barcodes. Barcodes ensure that a particular medication is given to the right patient through scanning and matching. Computerized physician order entry can also be used to prevent medication errors in the form of prescription errors (Billstein-Leber et al., 2018). It involves the prescription of medication electronically and linking the same to the pharmacy to reduce serious medication errors. The clinical decision support system has also been shown to prevent medication errors.
The other strategies that can be used to prevent medication errors include using personal digital assistants, using modified medication and prescription charts, mobile clinical assistants, minimization of the prescription illegibility, automation of dispensing machines, and use of robots when dispensing (Billstein-Leber et al., 2018). Educational initiatives can also be used to reduce the chances of medication errors occurring. For example, the education content offered to the clinicians can touch on the areas such as drug administration safety, drug interaction, adverse reaction, common medication system errors, and the medication process safe routes.
As earlier discussed, various strategies can be applied in efforts to address medication errors. As such, the solution chosen to address this problem is the use of barcodes. The bar code medication administration system has been shown to help reduce medication errors through an electronic verification of various medication administration activities including, the right route, right time, right drug, right dose, and the right patient (Thomson et al., 2018). In essence, when a clinician scans a bar code on the medication to be given to the patient, the patient’s wristband, and the identification badge, then the scanned data is analyzed in a computer system equipped with special software, which then returns medication approvals or warnings.
The use of a barcode system has both advantages and disadvantages. One of the main advantages is that it helps in reducing medication errors hence improving patient safety. It also leads to enhanced medication administration efficiency and eliminate human errors, which may result from fatigue and lack of concentration. Even though the use of this technology has various advantages, it has cons too. For example, it is relatively difficult to use the technology, especially if there is insufficient support and training. In some cases, there is a lack of relevant procedures, policies, and workflow (Thomson et al., 2018). The initial cost for acquiring and implementing the technology can be high. In addition, a malfunction or technical hitches can lead to further errors hence putting the patient’s safety at risk. It is worth noting that if the problem is ignored and no step is taken to solve it, there is a risk of continued medication errors that can further endanger the patient’s life.
Implementation and Ethical Implications
Implementing the bar code medication administration system requires that a particular facility make comprehensive plans on acquiring the relevant hardware and software, which could cost a considerable amount of money. The facility may also have to train staff to successfully implement and use the bar code medication administration system (Thomson et al., 2018). However, even though the implementation of the solution may be advantageous, it may have ethical implications. The first implication comes in the form of data security and data integrity. The use of a barcoding system requires the acquisition of patient details, which are then stored in a database. Such databases can be prone to cyber-attacks and data theft, exposing the patient’s private and confidential information.
Patient safety is one of the major concerns in any patient care environment; hence various stakeholders have been exploring efforts to ensure that patients are safe in the care settings and that their safety is not compromised. Medication errors cause a considerable threat to patient safety. Therefore, this paper has explored the context of medication errors in a patient care setting. Besides, the paper has also expounded on some of the strategies applicable in addressing the problem. Again the bar code medication administration system has been chosen as a model solution and various aspects of the same all discussed.
Billstein-Leber, M., Carrillo, C. J. D., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493-1517. https://doi.org/10.2146/ajhp170811
Gates, P. J., Baysari, M. T., Mumford, V., Raban, M. Z., & Westbrook, J. I. (2019). Standardizing the classification of harm associated with medication errors: The Harm Associated with Medication Error Classification (HAMEC). Drug safety, 42(8), 931-939. https://doi.org/10.1007/s40264-019-00823-4
Mieiro, D. B., Oliveira, É. B. C. D., Fonseca, R. E. P. D., Mininel, V. A., Zem-Mascarenhas, S. H., & Machado, R. C. (2019). Strategies to minimize medication errors in emergency units: an integrative review. Revista brasileira de enfermagem, 72, 307-314. https://doi.org/10.1590/0034-7167-2017-0658.
Nguyen, M. N. R., Mosel, C., & Grzeskowiak, L. E. (2018). Interventions to reduce medication errors in neonatal care: a systematic review. Therapeutic advances in drug safety, 9(2), 123-155. https://doi.org/10.1177%2F2042098617748868.
Thompson, K. M., Swanson, K. M., Cox, D. L., Kirchner, R. B., Russell, J. J., Wermers, R. A., … & Naessens, J. M. (2018). Implementation of barcode medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001
Assessment 3 Instructions: Analyzing a Current Health Care Problem or Issue.
- Write a 4-6 page analysis of a current problem or issue in health care, including a proposed solution and possible ethical implications.
In your health care career, you will be confronted with many problems that demand a solution. By using research skills, you can learn what others are doing and saying about similar problems. Then, you can analyze the problem and the people and systems it affects. You can also examine potential solutions and their ramifications. This assessment allows you to practice this approach with a real-world problem.
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Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum, be sure to address each point. In addition, you are encouraged to review the performance-level descriptions for each criterion to see how your work will be assessed.
- Describe the health care problem or issue you selected for use in Assessment 2 (from the Assessment Topic Areas media piece) and provide details about it.
- Explore your chosen topic. For this, you should use the first four steps of the Socratic Problem-Solving Approach to aid your critical thinking. This approach was introduced in Assessment 2.
- Identify possible causes for the problem or issue.
- Use scholarly information to describe and explain the health care problem or issue and identify possible causes for it.
- Identify at least three scholarly or academic peer-reviewed journal articles about the topic.
- You may find the How Do I Find Peer-Reviewed Articles? library guide helpful in locating appropriate references.
- You may use articles you found while working on Assessment 2 or you may search the Capella library for other articles.
- You may find the applicable Undergraduate Library Research Guide helpful in your search.
- Review the Think Critically About Source Quality to help you complete the following:
- Assess the credibility of the information sources.
- Assess the relevance of the information sources.
- Analyze the health care problem or issue.
- Describe the setting or context for the problem or issue.
- Describe why the problem or issue is important to you.
- Identify groups of people affected by the problem or issue.
- Provide examples that support your analysis of the problem or issue.ï»¿
- Discuss potential solutions for the health care problem or issue.
- Describe what would be required to implement a solution.
- Describe potential consequences of ignoring the problem or issue.
- Provide the pros and cons for one of the solutions you are proposing.
- Explain the ethical principles (Beneficence, Nonmaleficence, Autonomy, and Justice) if potential solution was implemented.
- Describe what would be necessary to implement the proposed solution.
- Explain the ethical principles that need to be considered (Beneficence, Nonmaleficence, Autonomy, and Justice) if the potential solution was implemented.
- Provide examples from the literature to support the points you are making.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
Your assessment should also meet the following requirements:
- Length: 4–6 typed, double-spaced pages, not including the title page and reference page.
- Font and font size: Times New Roman, 12 point.
- APA tutorial: Use the APA Style Paper Tutorial [DOCX] for guidance.
- Written communication: Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
- Using outside sources: Integrate information from outside sources into academic writing by appropriately quoting, paraphrasing, and summarizing, following APA style.
- References: Integrate information from outside sources to include at least three scholarly or academic peer-reviewed journal articles and three in-text citations within the paper.
- APA format: Follow current APA guidelines for in-text citations of outside sources in the body of your paper and also on the reference page.
Organize your paper using the following structure and headings:
- Title page. A separate page.
- Introduction. A brief one-paragraph statement about the purpose of the paper.
- Elements of the problem/issue. Identify the elements of the problem or issue or question.
- Analysis. Analyze, define, and frame the problem or issue.
- Considering options. Consider solutions, responses, or answers.
- Solution. Choose a solution, response, or answer.
- Ethical implications. Ethical implications of implementing the solution.
- Implementation. Implementation of the potential solution.
- Conclusion. One paragraph.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
- Competency 1: Apply information literacy and library research skills to obtain scholarly information in the field of health care.
- Use scholarly information to describe and explain a health care problem or issue and identify possible causes for it.
- Competency 2: Apply scholarly information through critical thinking to solve problems in the field of health care.
- Analyze a health care problem or issue by describing the context, explaining why it is important and identifying populations affected by it.
- Discuss potential solutions for a health care problem or issue and describe what would be required to implement a solution.
- Competency 3: Apply ethical principles and academic standards to the study of health care.
- Explain the ethical principles (Beneficence, Nonmaleficence, Autonomy, and Justice) if potential solution was implemented
- Competency 4: Write for a specific audience, in appropriate tone and style, in accordance with Capella’s writing standards.
- Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
- Write following APA style for in-text citations, quotes, and references.
- SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.
VIEW SCORING GUIDE
Analyzing a Current Health Care Problem or Issue Scoring Guide
|Does not use scholarly information to describe or explain a health care problem or issue or identify possible causes for it.||Describes a health care problem or issue but does not explain it, or identifies possible causes for a problem or issues but the identification is incomplete or inaccurate.||Uses scholarly information to describe and explain a health care problem or issue and identify possible causes for it.||Uses scholarly information to describe and explain a health care problem or issue and identify possible causes for it, and indicates which causes are the most likely.|
|Does not analyze a health care problem or issue by describing the context, explaining why it is important and identifying populations affected by it.||Identifies a health care problem or issue but does not analyze it.||Analyzes a health care problem or issue by describing the context, explaining why it is important and identifying populations affected by it.||Analyzes a health care problem or issue by describing the context, explaining why it is important and identifying populations affected by it, and provides examples that support the analysis.|
|Does not discuss potential solutions for a health care problem or issue and describe what would be required to implement a solution.||Incompletely or inaccurately discusses potential solutions for a health care problem or issue and what would be required to implement a solution.||Discusses potential solutions for a health care problem or issue and describes what would be required to implement a solution.||Discusses potential solutions for a health care problem or issue, describes what would be required to implement a solution, and describes potential consequences of ignoring the problem or issue.|
|Does not mention ethical principles if the potential solution was implemented.||Mentions ethical principles (Beneficence, Nonmaleficence, Autonomy, and Justice) that need to be considered if the potential solution was implemented but does not explain them.||Explains the ethical principles that need to be considered (Beneficence, Nonmaleficence, Autonomy, and Justice) if potential solution was implemented.||Explains the ethical principles that need to be considered if potential solution was implemented and enriches the analysis with examples from the readings.|
|Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.||Does not write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.||Writes clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics with some errors and lapses.||Writes clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.||Writes clearly and logically, using evidence to support a central idea, with correct use of spelling, grammar, punctuation, and mechanics and ensures the paper contains supporting examples for the main points.|
|Write following APA style for in-text citations, quotes, and references.||Does not write following APA style for in-text citations, quotes, and references.||Writes following APA style for in-text citations, quotes, and references with some errors and lapses.||Writes following APA style for in-text citations, quotes, and references.||Writes following APA style for in-text citations, quotes, and references without errors and uses current reference sources.|