Proposal on Preventing of Medication Errors
Introduction
Safety of patients is a critical element worth considering among healthcare providers (HCP) worldwide. According to the Food and Drug Administration (FDA), a medication error is a preventable incident potentially resulting in the inappropriate use of medication or harm a patient while it is under a clinician, patient, or consumer’s control (2018). The impacts of medication errors are adverse, including reduced healthcare outcomes, increased healthcare costs and significant mortality rates (WHO,2016). Gnadinger (2017) indicates that medical errors are the third leading cause of death in the United States. Despite the association of medication errors occurring in the inpatient units, their occurrence in the outpatient settings is significantly higher (Patient Safety Network, 2018). Minimizing medical errors in health care organizations is essential in measuring healthcare outcomes. Such outcomes are critical in achieving the Quadruple Aim of Healthcare-improving patient experience of care, improving the health of populations, reducing the per capita cost of healthcare, and reducing clinician and staff burnout.
This article provides a succinct description of the purpose and proposal to prevent medication errors in my healthcare organization. Opportunities for embracing change within the organization prompt me to communicate the need for change. The proposal discussion will provide the best available evidence through peer-reviewed articles. As health care professionals, we have both moral and legal obligations to ensure quality and seamless care to our clients, including preventing and minimizing medical errors for improved patient outcomes and improved financial implications.
Organization
On many occasions, as a nurse working in the diabetic outpatient setting in Boost Health Center, I encounter potential risks in the prescription, dispensation, administration, monitoring, and offering advice regarding medications. Boost Health Center has increasingly reported an upsurge in medication errors recently. However, there exists a well-established network of collaboration among healthcare workers in the facility. Considering that the healthcare sector is ever fast-paced and ever-evolving, change remains continuous and inevitable. As organizational executives, we have collaborated over the years to ensure a broad and well-established organization culture that embraces change.
Health care executives have an ongoing, iterative process that has enabled the strategic alignment of the Boost Health Center to embrace change. Some of the iterative methods utilized include social processes where we engage clinicians in negotiations concerning impending healthcare proposals and feedback loops to obtain feedback from clinicians, patients and the community in a bid to instil an organizational culture embracing change. All healthcare workers remain focused towards upholding corporate values which major on delivery of quality health care services and minimizing errors using innovative approaches. Besides, employee engagement in decision-making, inclusivity and using the bottom-up approach has also necessitated a well-established culture for change and reduced resistance.
Improvement Opportunity
Medication errors often lead to deterioration of patient health, increased morbidities, high healthcare costs, and increased mortality rates. Medication errors undermine patient safety, thus leading to inadequate outcome measures which re driven by national standards and financial incentives. Safety of care concerning medical mistakes and errors is one of the outcome measure group used by CMS to calculate hospital quality (Tinker, 2019). Such scores influence the reimbursement rates for health care organizations, physicians, and nurses, by commercial payers, and the insurance companies. The high incidences of medication errors in Boost Health Center ought to be addressed using medical technology and education to improve patient safety and shift towards desired healthcare outcomes, thus, improve the finances acquired through reimbursement rates.
Purpose
My proposal’s purpose gets aimed at minimizing and preventing medical errors that have, in the recent past, on an upsurge to avoid adverse patient outcomes. The initiative involves the use of Electronic Health Record by using computerized physician order entry with improved communication and collaboration, enhancing the practice of patient engagement. Reports from some nurses include myself indicate the occurrence of errors in drug prescription through transcription that occurs as a result of poor communication between physician-to-nurse and nurse-to-pharmacy and lack of communication when providing medical advice to a patient. Healthcare research evidence demonstrates that relying on new technological innovations including computerized physician order entry remains relevant in reducing medical errors and improving health outcomes (Overhage, Gandhi, Hope, et al., 2016: Whitley, Ennis, Taaca, et al., 2018).
Proposal Initiative
Utilization of Electronic Health Records (EHR) will potentially reduce medication errors through computerized prescription. Computerized physician order entry system with clinical decision support systems will be implemented. Clinical decision support systems (CDSS) with features such as suggestions for dosage, route and frequency prevent medication errors (Overhage et al., 2016). Using such an EHR system will enable standardized prescriptions with completeness and legibility. CDSS also include alarming support when an error gets made through keying in of wrong information regarding prescription or a patient, examples of medication errors that occur. The system will also enable the authorized health care providers to gain access to patient information, order medications and prescribe, thus reducing medical errors caused by prescriptions given by wrong personnel. Real-time access to medical information in one system will also reduce confusion and improve communication among healthcare providers and pharmacists, and patient engagement because an updated intervention gest recorded in one platform. In that way, medical errors will be reduced and prevented in Boost Health Center and translate to- improved patient outcomes and increased patient experiences- increased reimbursement rates.
Leadership Role
The hospital leadership and management team has played a critical role in facilitating the development of this proposal. Collaboration between the hospital’s executive members remains effective. Also, engagement with the Chief Nursing Executive Officer and the Pross Improvement Team, over time, has identified the need to prevent medication errors in the facility to realize our facility vision. Further, the leadership team have established and communicated a clear vision to all stakeholders of Boost Health Center as a leadership strategy to effect change using an interdisciplinary approach. Nguyen, Thomson, Jarjour, et al. (2019) assert that establishment and communicating a clear vision are the leadership strategy to lead the interdisciplinary solution effectively. Consequently, the engagement of health care providers is gradually inviting their collaboration to the need for change and get motivated in collaborating for the new change.
References
Nguyen, H. B., Thomson, C., Jarjour, N. N., Dixon, A. E., Liesching, T. N., Schnapp, L. M., … & of the Association, L. W. G. (2019). Leading Change and Negotiation Strategies for Division Leaders in Clinical Medicine. Chest, 156(6), 1246-1253
Overhage, J. M., Gandhi, T. K., Hope, C., Seger, A. C., Murray, M. D., Orav, E. J., & Bates, D. W. (2016). Ambulatory computerized prescribing and preventable adverse drug events. Journal of Patient Safety, 12(2), 69-74. doi:10.1097/PTS.0000000000000194
Tinker, A. (2019, June 7). The Top 7 Healthcare Outcomes Measures. Health Catalyst. https://www.healthcatalyst.com/insights/top-7-healthcare-outcome-measures.
Whitley, P., Ennis, E., Taaca, N., Sneha, S., Shahriar, H., & Zhang, C. (2018, September). Reduction of Medical Errors in Emergency Medical Care. In Proceedings of the 19th Annual SIG Conference on Information Technology Education (pp. 160-160).
World Health Organization. (2016). Medication errors. World Health Organization.