The objective of every health care organization
The objective of every health care organization is to offer quality healthcare that guarantees patient safety and positive outcomes. However, in the course of the provision of care, some events occur, which may hinder the quality of care given to patients. Aspden, Corrigan, Wolcott, & Erickson (2004) define an adverse event as “any event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.” The damage caused by adverse events ranges from minor injury to severe mutilation, and sometimes even leading to death. One of the most common causes of adverse events in a healthcare organization is medication errors. In the United States of America, it is estimated that every year, between 7,000 to 9,000 lives are lost due to medication error (Tariq & Scherbak, 2019). Moreover, approximately $40 billion is spent every year in looking after patients with medication-induced errors. Medication errors can occur at any stage of patient treatment, making it a grave topic for discussion (Tariq & Scherbak, 2019).
In my place of work, I am assigned to the tuberculosis department. We handle patients with both active and latent Tuberculosis cases right from diagnosis to cure. During the patients’ treatment, our duties include, among other things, drug administration to the patients. The standard process of tuberculosis medication flow is that a physician first orders the medication. The order is then transmitted to the State TB Department. The State TB Department then ensures that the medication is dispatched to the local health unit for dissemination to the patient. The local health unit, the State TB program, and the pharmacy all must confirm that the correct medication is ordered at the accurate dose, for the precise amount of time before being given to the patients. Therefore, our duties as nurses are to ensure that the correct medication is given to the patients based on the physician’s recommended regimen.
Analyze the missed steps or protocol deviations related to an adverse event or near-miss.
Medication errors can occur at the ordering, documenting, transcribing, dispensing, administering, or at the monitoring stage (Tariq & Scherbak, 2019). In March this year, I was involved in an incident of mediation error with one of my TB patients, a highly regrettable incident. The patient in question had a latent tuberculosis case and had been scheduled for a once a week medication program. The correct dosage for the medication is 900 mg weekly of Isoniazid and 900 mg weekly of Rifapentine for 12 weeks. However, despite the standard dosage, there can be variations since these dosages are weight-based. The physician had initially made an order for the standard 900 mg of Isoniazid and 900 mg of Rifapentine. Before sending the order to the state TB department, I reviewed the physician’s order. Still, I failed to take note of the patient’s weight being low, thereby deserving a much lesser dose of Isoniazid. The state TB department noted the error and sent the order back for correction. I contacted the physician, who agreed to reduce the dose of Isoniazid to 750mg. Once the error was corrected, the State TB department dispatched the order to the pharmacy for dispensation.
Upon receiving the medication, I contacted the patient to set up a time for the commencement of the treatment. When setting up and administering the medication, the standard procedure is to adhere to the five rights of safe drug administration. The five rights include the right patient, the right drug, the right dose, the right route, and the right time (Martyn, Paliadelis, & Perry, 2019). The five rights of safe drug administration have been found to reduce the occurrence of medication errors and harm to patients. However, while administering the drugs to the patient, I failed to adhere to the five rights of safe drug administration. This was evident as I failed to validate the accurate dose during medication set up. I set the pillbox to contain 900 mg instead of the 750 mg dose, by erroneously presuming that the patient was on the standard dose of Isoniazid. Moreover, I failed to check the dose during the actual drug administration.
Based on the finding of Tariq & Scherbak (2019), one of the most important causes of medication errors is distractions. Healthcare practitioners regularly engage in distractions such as speaking to consultants, speaking to patient family members, while setting up medication. In the long run, these distractions can cause errors. Nearly 75% of medication errors have been attributed to distraction. In my case, I got distracted by the numerous question from the patient and his family during the drug set and administration. When I learned about the incidence, I got traumatized. Luckily, the mistake did not harm the patient. However, it strained the relationship between myself, the patient, and the patient family. Healthcare organizations and practitioners should have structures that can help reduce distractions.
Analyze the implications of the adverse event or near-miss for all stakeholders
The healthcare sector is very crucial as it deals with human life. Since the safety of human life is at stake, the occurrence of adverse events may have emotional, psychological, and professional implications on all stakeholders. In the phase of such adverse events, the first victim is patients and their families, while health care practitioners and the healthcare organization are the second and third victims, respectively (Taylor & Jones, 2019).
The first category of the stakeholder who can be affected by an adverse or near-miss event is the patient and the patient family. An adverse event may cause minor or severe injury to the patient. In some instances, it may cause death to the patient. In the event of an injury or death, the patient family will feel aggravated. The family may also develop hatred towards healthcare professionals and may be hesitant to seek medical attention (Taylor & Jones, 2019). In my case, I was lucky that the increase in Isoniazid did not have an adverse injury on the patient since the 900 mg was still within a therapeutic drug range for the patient, it irreversibly fractured the relationship between them and me. Every time the patient and his family visited the facility, they ensured they had a copy of the medication order to confirm the pills in the container before taking the medications.
The second and the thirds category of stakeholders are the healthcare professionals and the healthcare organization, respectively. The healthcare professional may get traumatized and lose confidence (Taylor & Jones, 2019). The incidence can also damage one’s career, making it difficult for them to secure a new job in case of a job loss. In my case, I got extremely traumatized. For healthcare organizations, the occurrence of adverse events may damage its reputation, and there discourage people from seeking treatment in that facility. Moreover, a hospital may forego a significant amount of reimbursement money since Medicaid and Medicare services do not cover damages ensuing from preventable errors (Taylor & Jones, 2019).
It is, therefore, crucial that healthcare organizations instigate measures to reduce the occurrence of medication errors. One strategy is through the automation of health care technologies.
Evaluate quality improvement technologies related to the event that is required to reduce risk and increase patient safety.
The consequences of medication errors can be so severe for all the stakeholders involved. Subsequently, it is important to have measures that can help reduce the occurrence of errors. One of the quality improvement technologies that can help reduce the errors in the use of Electronic health records (EHRs) (Yadav, Steinbach, Kumar, & Simon, 2018). An electronic health record (EHR) is a digital format of a patient’s paper chart. EHRs is highly recommended over the paper chart because it provided real-time, patient-aligned records that make patient data promptly accessible and safe to authorized users.
Some of the measures through which EHR can help reduce the occurrence of medication errors include (1) enabling the care providers to promptly and methodically pinpoint and correct operational problems, (2) rev
- g potential safety risks when they occur, consequently allowing the care providers to avoid more se
- injury for patients, (3) automatically checking for discrepancies whenever a new medication is recommended and signals the clinician
possible conflicts (Yadav, Steinbach, Kumar, & Simon, 2018).
- The criteria through which the Electronic health records can be evaluated include, (1) upholds basic EHR adoption
n and data gathering, (2) underlines care coordination and exchange of patient information, (3) advances healthcare outcomes.
Incorporate relevant metrics of the adverse event or near-miss incident to support the need for improvement.
Electronic health records represent an important patient database that can help in guaranteeing positive patient outcomes. It has information about patient medical history, vital signs, patient complainants, allergies, and laboratory results. Moreover, it allows the interdisciplinary team to handle a patient to have a clear view of the patient’s entire health record (Yadav, Steinbach, Kumar, & Simon, 2018).
Electronic health records help to reduce many errors in several ways. It enables the care providers to promptly identify pinpoint and correct operational problems, it exposes potential safety risks when they occur, consequently allowing the care providers to avoid more severe injury for patients, and it automatically checks for discrepancies whenever a new medication is recommended and signals the clinician to possible conflicts (Yadav, Steinbach, Kumar, & Simon, 2018). If we had installed this technology in our facility, I would have been able to identify the inaccurate dosage and corrected it before administering it to my TB patient.
Previous studies that have been conducted to assess the effectiveness of healthcare technologies such as EHR in reducing the occurrence of medication errors have shown that EHR has significantly reduced the frequency of medication errors (Taylor & Jones, 2019; Hunt & Chakraborty, 2019).
Outline an evidence-based quality improvement initiative to prevent an adverse event or near-miss.
Healthcare organizations have tried to adopt an evidence-based quality improvement initiative to prevent an adverse event or near-miss due to the risk posed by medication errors. One of the strategies of reducing errors is to improve communication between healthcare professionals. Miscommunications are believed to account for a substantial portion of adverse events, specifically during handoffs. The data from the Joint Commission estimates that miscommunication among care providers is responsible for 80 percent of serious medical errors (Shahid & Thomas, 2018).
The most appropriate initiative to improve communication and reduce the occurrence of errors is the SBAR communication strategy. The SBAR (Situation-Background-Assessment-Recommendation) is a technique that offers a structure for communication among care providers about a patient’s condition. The SBAR can help reduce the occurrence of medication errors by
- effectively joining the differences in communication styles and helping to get all care providers to be on the same page,
- it offers a common, reliable and predictable framework for communication,
- it provides procedures for organizing pertinent information when getting ready to contact another team member (Shahid & Thomas, 2018).
According to Ting, Peng, Lin, & Hsiao, (2017), SBAR, as an evidenced-based communication technique, has proved to promote competent communication that stimulates effective teamwork and advance positive patient outcomes.
Conclusion
Medication errors are one of the leading causes of injuries in healthcare facilities across the world. In the United States of America, about 7,000 to 9,000 lives are lost due to medication error, and more than $40 billion is spent every year looking after patients with medication-induced errors. By integrating the Electronic health records and having a proper communication structure among care providers.