Capella 4020 Assessment 1 Enhancing Quality and Safety

Name

Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Enhancing Quality and Safety

Medication errors are the most significant factor of preventable patient harm in the global medical care setting. Medication Administration Errors (MAEs) are one of the more frequently occurring medical mistakes, which have severe implications for patients, medical personnel, and medical organizations (Wondmieneh et al., 2020). The World Health Organization (WHO) reported that the worldwide economic impact of drug errors is anticipated to be nearly 42 billion dollars yearly (Asefa et al., 2021). MAEs cause the mortality of around 7000 patients and cause approximately 400,000 occurrences of unnecessary patient damage in the United States each year (Wondmieneh et al., 2020). This study will examine a case illustrating the drug administration’s safety and quality challenges. 

Scenario 

Mr. John, a 52-year-old man with a diagnosis of cardiac myopathy, was hospitalized for prolonged care and treatments. A mistake in medicine administration happened during Mr. John’s hospitalization. Instead of his prescribed drugs, he was provided with the wrong medication by a nurse who misinterpreted the medication’s prescription. Tragically, the mistake was ignored until Mr. John’s condition progressively declined.  The drug he acquired by mistake had a detrimental interaction with his other medicines. He had an elevated cardiovascular rate and breathing problems, which exacerbated his condition. The physician and the medical professionals evaluated Mr. John’s condition, and the MAE was found as a possible cause. Mr. John was then given immediate medical attention to help manage his health.  This tragic event reminded the medical professionals in the healthcare setting of the importance of the safety of the medication. 

Factors Leading to Patient Safety Risk

MAEs can cause severe health hazards to patients. Many factors contribute to patient safety hazards during pharmaceutical delivery. Poor teamwork and inadequate communication and interaction among doctors and nurses are some of the contributing factors to MAEs. Lack of collaboration among medical personnel can result in medication errors (Tiwary et al., 2019). Mr. John’s medication was administered incorrectly due to a misunderstanding and lack of communication among nurses and specialists. Misunderstanding and a lack of multidisciplinary cooperation result in insufficient information exchange among physicians, nurse practitioners, and pharmacy professionals, which can harm patients and increase medical expenditures. To prevent such events, efficient interaction is vital (Tiwary et al., 2019).

Other recognized reasons for MAEs include errors in written correspondence, such as prescription drugs and record-keeping, drug delivery and inventory problems, such as pharmacy errors in dispensing, and facility management of stock. According to various studies, excessive job stress of nurses contributes to MAEs (Ayorinde & Alabi, 2019).  However, the majority of MAEs impacting patients in hospitals happen at the bedside and arise when a drug dose is provided inappropriately (Ayorinde & Alabi, 2019).

MAEs are more likely in patients who have complicated drug regimes. Many research investigations have found a link between pharmaceutical regimen complexity and an increased likelihood of mishaps (Jessurun et al., 2023). Mr. John’s history of cardiac myopathy most likely demanded an elaborate drug prescription. Using standardized verifying techniques can help reduce the chance of misunderstanding and mistakes. Medical professionals can minimize the chance of MAEs in people like Mr. John by highlighting the significance of verification of prescriptions (Jessurun et al., 2023).

Solutions Based on Evidence-Based Best Practices 

Increased incidents of MAE results in a financial burden on patient and the healthcare system. Evidence-Based Practice (EBP) educates medical professionals on the most effective drugs or medications for particular diseases (Patel et al., 2019). EBP allows clinicians to select medicines with fewer adverse drug reactions. EBP enables physicians to administer Mr. John’s drug regimen effectively. EBP can significantly reduce MAEs, such as duplicate and incorrect dosages, and save medical expenses (Ahsani et al., 2022). Here are several EBPs that can assist in reducing MAEs:

Medication Error Reporting System

Introducing the Medication Error Reporting System (MERS) aids in identifying potential sources or risk factors of drug mistakes. Medication error reporting provides valuable information highlighting areas that require improvement to enhance patient safety (Mutair et al., 2021). Additionally, MERS is essential for assisting in easily avoiding errors and their typical serious consequences. Through MERS, healthcare professionals can evaluate contributing and risk variables in MAEs and the frequency of prescription mistakes. This system is critical to avoiding medication adverse events (Mutair et al., 2021).

Barcoding Medication Administration (BCMA)

BCMA functions as a beneficial Clinical Decision Support System (CDSS) to reduce medication errors. The BCMA technique can improve medicine delivery precision and effectiveness (Shitu et al., 2019). The scanning of barcodes verifies the drug information, guaranteeing the relevant patient, the right medicine, dosage, and mechanism is used. The BCMA system assists nurses in appropriately diagnosing patients and preventing MAEs. This approach enables hospitals and clinics to meet patient safety objectives (Mulac et al., 2021).

Computerized Physicians’ Order Entry System (CPOE)

The CPOE system helps nurses deliver medications currently functioning in the system. Using CPOE systems has been estimated to prevent around half of all medication errors (Jungreithmayr et al., 2021). A drug prescription should meet requirements such as legibility and accuracy to avoid MAEs. CPOE systems can significantly minimize unclear prescriptions and data exclusion, typical contributors to medication errors (Jungreithmayr et al., 2021).

Medication Reconciliation (MR)

MR is crucial to eliminate exclusion and replication errors, improper dosages or schedules, and harmful or adverse drug interactions. Adverse events can be reduced to improve patient safety by efficient MR, reducing the unwanted hospital stay of patients and mitigating healthcare costs (Chiewchantanakit et al., 2020). The MR strategy for Mr. John can help guarantee that his prescription information is updated during his hospitalization. This procedure involves contrasting his medicines with the drug prescription (Elbeddini et al., 2021).

The Role of Nurses in Coordinate Care for Patient Safety

Medication errors adversely affect patient safety. MAEs can result in extended hospital stays, incurring significant costs for medical facilities and individuals.  Nurses can avoid these additional expenditures by playing their role in coordinating care (Mileski et al., 2020). Nurses can follow evidence-based drug safety procedures such as the five rights of drug management, including the right patient, prescription drugs, dosage, met

hod of administration, and timing. Nurses regularly give the right medicine to relevant patients by following these rules or guidelines (Hanson & Haddad, 2023). Moreover, nurse practitioners can clarify the function of each medicine and address any possible adverse reactions. They increase the safety of drugs and decrease consequences by providing Mr. John with details regarding his medicines. They can guide him about the dosage and timing of medication. Nurses also play a significant role in identifying pharmacological inconsistencies and coordinating with other medical professionals, including pharmacists, to mitigate this issue (Mardani et al., 2020).

 Nurses can work with the multidisciplinary groups involved in Mr. John’s treatment. By actively engaging in multidisciplinary duties, nurses can exchange experiences and play a part in establishing holistic care plans. Coordination improves patient safety, lowers the chance of MAEs, and minimizes medical expenses (Dirik et al., 2019). Nurses are also vital for efficient communication and interaction with patients to provide proper guidance and legitimate or updated knowledge about medication to avoid unwanted consequences, reducing the medical cost by preventing hospitalization of patients. They can develop an understanding of Mr. John’s pharmaceutical requirements and improve patient safety by facilitating straightforward communication. They help him to overcome the adverse reactions of drugs (Jeong & Park, 2022).

Care Coordination and Stakeholders

Nurses need to collaborate with multidisciplinary groups or stakeholders to improve drug delivery safety and efficacy. It is necessary to develop patient trust on medical system and create a trust worthy relationship between patient and healthcare providers. Pharmacists and doctors are crucial for collaboration with nurses to enhance the standard of care. Nurses collaborate with doctors and clinicians to ensure that medication prescriptions are correct and to obtain confirmation when needed. Cooperation among stakeholders is essential to maintaining reliable and efficient drug delivery procedures (Mardani et al., 2020). Nurses work with pharmacists to confirm prescription demands and ratios and drug administration schedules. Nurses gain knowledge from pharmacists about drug interaction and deal with adverse drug reactions through collaboration (Mardani et al., 2020). Pharmacists ensure that the right medicines are provided with the appropriate dosages to enhance patient safety (Jaam et al., 2021).

Information Technology (IT) professionals are vital players in drug delivery systems. With the collaboration of nurse Informaticists, IT professionals assist nurses by installing and optimizing technical devices or systems, for example, BCMA, CPOE, and MERS (Ho & Burger, 2020). Nurses interact with IT professionals to manage these systems and ensure they operate according to their requirements. Stakeholders, including IT professionals and nurse informaticists, can work together to tackle technical challenges and ensure that these innovative systems efficiently enhance medicine delivery procedures (Ho & Burger, 2020). Coordination and partnership improve patient safety by improving the medication system.

Conclusion

Mr. John’s case study emphasizes the substantial care and quality concerns in medication. One patient safety issue is medication delivery, which necessitates prompt response to improve patient health and prevent harm. Evidence-based interventions can improve safeguards for patients and reduce MAEs. Nurses are responsible for adhering to Institute of Medicine (IOM) guidelines, enhancing interpersonal skills and communication, and collaborating with other healthcare providers to assure patient safety and enhance care quality.

References

Ahsani, E., Sergeevich Gordeev, V., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews. Frontiers in Medicine, 9, 875426. https://doi.org/10.3389/fmed.2022.875426

Asefa, K. K., Dagne, D., & Mekonnen, W. N. (2021). Medication administration error reporting and associated factors among nurses working in public hospitals, Ethiopia: A cross-sectional study. Nursing Research and Practice, 2021, 1-8. https://doi.org/10.1155/2021/1384168

Ayorinde, M. O., & Alabi, P. I. (2019). Perception and contributing factors to medication administration errors among nurses in Nigeria. International Journal of Africa Nursing Sciences, 11, 100153. https://doi.org/10.1016/j.ijans.2019.100153

Chiewchantanakit, D., Meakchai, A., Pituchaturont, N., Dilokthornsakul, P., & Dhippayom, T. (2020). The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis. Research in Social and Administrative Pharmacy, 16(7), 886-894. https://doi.org/10.1016/j.sapharm.2019.10.004

Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5-6), 931-938. https://doi.org/10.1111/jocn.14716

Elbeddini, A., Almasalkhi, S., Prabaharan, T., Tran, C., Gazarin, M., & Elshahawi, A. (2021). Avoiding a med-wreck: A structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources. Journal of Pharmaceutical Policy and Practice, 14(1), 1-10. https://doi.org/10.1186/s40545-021-00296-w

Capella 4020 Assessment 1 Enhancing Quality and Safety

Hanson, A., & Haddad, L. M. (2023, September 4). Nursing Rights of Medication Administration. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560654/

Hawkins, S. F., & Morse, J. M. (2022). Untenable expectations: Nurses’ work in the context of medication administration, error, and the organization. Global Qualitative Nursing Research, 9, 23333936221131779. https://doi.org/10.1177/23333936221131779

Ho, J., & Burger, D. (2020). Improving medication safety practice at a community hospital: A focus on bar code medication administration scanning and pain reassessment. British Medical Journal Open Quality, 9(3), e000987. http://dx.doi.org/10.1136/bmjoq-2020-000987

Jaam, M., Naseralallah, L. M., Hussain, T. A., & Pawluk, S. A. (2021). Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis. Plos One, 16(6), e0253588. https://doi.org/10.1371/journal.pone.0253588

Jeong, H. J., & Park, E. Y. (2022). Patient-nurse partnerships to prevent medication errors: A concept development using the hybrid method. International Journal of Environmental Research and Public Health, 19(9), 5378. https://doi.org/10.3390%2Fijerph19095378

Capella 4020 Assessment 1 Enhancing Quality and Safety

Jessurun, J. G., Hunfeld, N. G. M., de Roo, M., van Onzenoort, H. A. W., van Rosmalen, J., van Dijk, M., & van den Bemt, P. M. L. A. (2023). Prevalence and determinants of medication administration errors in clinical wards: A two‐centre prospective observational study. Journal of Clinical Nursing, 32(1-2), 208-220. https://doi.org/10.1111%2Fjocn.16215

Jungreithmayr, V., Meid, A. D., Haefeli, W. E., & Seidling, H. M. (2021). The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation—a before-and-after study. Bio Med Central Medical Informatics and Decision Making, 21, 1-12. https://doi.org/10.1186/s12911-021-01607-6

Mardani, A., Griffiths, P., & Vaismoradi, M. (2020). The role of the nurse in the management of medicines during transitional care: A systematic review. Journal of Multidisciplinary Healthcare, 1347-1361. https://doi.org/10.2147/JMDH.S276061

Mileski, M., Pannu, U., Payne, B., Sterling, E., & McClay, R. (2020). The impact of nurse practitioners on hospitalizations and discharges from long-term nursing facilities: A systematic review. Healthcare, 8(2), 114–114. https://doi.org/10.3390/healthcare8020114

Mulac, A., Mathiesen, L., Taxis, K., & Granås, A. G. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. British Medical Journal Quality & Safety, 30(12), 1021-1030. https://doi.org/10.1136%2Fbmjqs-2021-013223

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390%2Fmedicines8090046

Capella 4020 Assessment 1 Enhancing Quality and Safety

Patel, R. S., Sekhri, S., Bhimanadham, N. N., Imran, S., & Hossain, S. (2019). A review on strategies to manage physician burnout. Cureus, 11(6). https://doi.org/10.7759/cureus.4805

Shitu, Z., Aung, M. M. T., Kamauzaman, T. H. T., Bhagat, V., & Rahman, A. F. A. (2019). Medication error in hospitals and effective intervention strategies: A systematic review. Research Journal of Pharmacy and Technology, 12(10), 4669-4677. http://doi.org/10.5958/0974-360X.2019.00804.7

Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by health care professionals may lead to life-threatening complications: Examples from two case reports. Wellcome Open Research, 4. https://doi.org/10.12688%2Fwellcomeopenres.15042.1

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. Bio Med Central Nursing, 19(1), 1-9. https://doi.org/10.1186/s12912-020-0397-0

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