Medication Errors Improvement Plan Tool Kit

Summary

The primary goal of this assignment is to create a toolkit for nurses to use in safety improvement initiatives that would help decrease medication errors while also improving clinical outcomes. The 12 annotated materials in this toolkit will be broken down into four categories: the causes of medication errors, the dangers they pose to patient safety, evidence-based methods for medical error reduction, and healthcare policies and plans for reducing medication errors.

Annotated Bibliography

Medication Errors Causes

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., Biermann, J. S., & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10, 20. 

This scholarly article talks about how to identify the underlying reasons for medication errors and also illustrates the measures to stop medication errors from happening again. The article lists 9 steps to perform a root cause analysis for medication errors: to define an adverse reaction, to assemble a team, to create an immediate flow diagram, to create an event story map, to create a case diagram, to recognize underlying cause and factors that contribute, to establish a corrective measure, to measure outcomes, and to present the information. This tool helps healthcare professionals do root cause analyses to determine preventive measures inside the healthcare system that will safeguard people. For instance, after reading this source, healthcare workers can utilize these procedures as tools to comprehend the causes and preventative measures for medication errors in the healthcare environment.

Gorgich, E.A., Barfroshan, S., Ghoreishi, G., &Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses’ and nursing student viewpoint. Global Journal of Health Science, 8(8), 44448. 

According to this medical journal, drug errors are caused by a variety of circumstances. Medication errors, in the nurses’ opinion, can be brought on by a high workload, a low nurse-to-patient ratio, distraction, an overstimulated environment, as well as a doctor’s order that is difficult to interpret. Common drug prescription mistakes include misjudging the concentration of the drug, failing to observe the proper dosage, exceeding the recommended amount, and failing to observe the proper method of administration. According to the nursing students’ respondents, the biggest contributors to medication errors include incorrect drug calculations, a lack of pharmacological knowledge, and doctors’ unclear or damaged instructions on medication cards. Additionally, a strong correlation between gender and medication errors among nursing students.

Getnet, M. A., & Bifftu, B. B. (2017). Work interruption experienced by nurses during the medication administration process and associated factors, northwest Ethiopia. Nursing Research and Practice, 8937490. 

The study was conducted to evaluate the risk of pharmaceutical errors related to work interruptions when preparing and administering drugs. The authors of the study show that work interruptions can be the result of self- or other-initiated actions, operator error, or external factors. These factors not only compromise patient safety but also negatively impact employees’ general well-being by increasing stress, anxiety, and dissatisfaction as well as increasing workload. The article gives readers the resources they need to comprehend the aspects of work interruption that may have an impact on patient safety and the process for administering medications. The authors further advise the nurse to focus while working and raise awareness of the impact of interruptions.

Risks Posed to Patient Satiety by Medication Errors

Elnour, A. A., Ellahham, N. H., & Al Qassas, H. I. (2008). Raising the awareness of inpatient nursing staff about medication errors. Pharmacy World & Science, 30(2), 182-90.

This study examines patient care, side effect, prescription inaccuracies, and the six rights of drug administration. The authors advise nurses to increase patient understanding of prescription errors and other safety concerns. The results of the study recommend using technological solutions to enhance communication between clinical pharmacists and nurses and implementing patient care. Additionally, adhering to the six rights: right patient, right medication, right time, right dosage, right route, and right indication, may help to lower the incidence of medication errors in clinical settings. The systematic program of the medical professional has increased the understanding of the in-patient nursing staff by increasing their awareness to prescribing errors.

Ghenadenik, A., Rochais, E., Atkinson, S., & Bussieres, J.F. (2012). Potential risks associated with medication administration, as identified by simple tools and observations. The Canadian Journal of Hospital Pharmacy, 65(4), 300-307. 

This article explains how a medical error is an avoidable incident that can have serious health and safety implications, including morbidity, higher healthcare expenses, longer hospital stays, more medical management, personal injury, or even death. A few patient health hazard considerations have been discussed, and the article’s four phases included a complete explanation of the administration of medication, a diagrammatical representation of the procedure, an observation-based audit of the procedure, a review of the findings, and the establishment of guidelines. As described in this article, it is crucial for patient care to confirm a patient’s identity twice to prevent incorrect patient drug provision when it is time to take a dose. The study also covered the connection between a nurse’s organization and the likelihood of mistakes, as well as the effects of interruptions when preparing medications. This resource is beneficial because it offers a variety of preventive measures that nurses can use to reduce the likelihood of medication errors. It also suggests corrective measures and straightforward tools combined with close observation that can successfully identify potential dangers.

Gates, P. J., Baysari, M. T., Mumford, V., Raban, M. Z., & Westbrook, J. I. (2019). Standardising the classification of harm associated with medication errors: The harm associated with medication error classification. Drug Safety, 42(8), 931–939.

The purpose of this study is to evaluate the harm caused by pharmaceutical errors, which has been divided into two categories: identifying prospective or real patient harm associated with a medication incident, and categorizing the severity of that injury. Significant harm brought on by drug mistakes might cause the patient serious harm. The resource advises classifying the harm and evaluating its seriousness in order to determine the preventative to lower the chance of pharmaceutical errors. The authors recommend that the level of harm caused by errors in addition to their frequency, must be quantified in order to better understand the effect of pharmaceutical errors on patient safety.

Intervention to Reduce Medication Errors

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. BMC Nursing, 19(1), 1-9.

This article focused on the many causes of pharmaceutical administration errors, which can happen at any point during the treatment procedure. The frequent sorts of medicine administration errors mentioned in the article include wrong timing, wrong individual, incorrect dosage, wrong prescription, improper route, absence of documentation, and system fault, all of which are the nurse’s fault. The authors advise nurses to follow the five rights of drug administration and report any mistakes. Another recommendation for a healthcare environment includes ongoing reinforcement of training and instruction on safe drug administration, as well as the creation of a safer drug administration setting and staff access to drug administration guidelines.

Berdot, S., Roudot, M., Schramm, C., Katsahian, S., Durieux, P., & Sabatier, B. (2016). Interventions to reduce nurses’ medication administration errors in inpatient settings: A systematic review and meta-analysis. International Journal of Nursing Studies, 53, 342–350. 

The authors recommend a number of treatments for the prevention and control of medication use, including the use of technology, teamwork, pharmacist engagement, organizational regulations, improved work environments, and leaflet distribution. This article is beneficial because it raises healthcare professionals’ knowledge of the need to employ evidence-based tactics to reduce drug mistakes. To help prevent such errors, a number of treatments, including barcode-based technologies, have been created. This article demonstrates a comprehensive review concentrating on the effectiveness of treatments for lowering medication delivery errors. Effective teamwork is crucial for patient safety because it reduces the likelihood of negative incidents brought on by confusion of duties and obligations and miscommunications with other healthcare professionals who are caring for the patient.

Agrawal A. (2009). Medication errors: Prevention using information technology systems. British Journal of Clinical Pharmacology, 67(6), 681-686.

The hazards brought on by medication administration errors and the consequences of unfavorable drug interactions are examined and discussed in this article. This scholarly article examines various technological systems critically in an effort to combat prescription mistakes. The researcher states that there is mounting evidence that the use of information technology, such as electronic prescribing and electronic medication reconciliation, is essential for preventing medication errors, improving standardization, and achieving positive patient outcomes. This article provides healthcare professionals with some tactics for preventing and reducing prescription errors and promoting patient safety through the use of computer technology. Economic incentives and governmental regulations must be used to overcome significant obstacles, for example, the high prices of these systems. The current state of information systems for reducing pharmaceutical errors is reviewed in this research.

Healthcare Policies

Khalil, H., Bell, B., Chambers, H., Sheikh, A., & Avery, A. J. (2017). Professional, structural and organizational interventions in primary care for reducing medication errors. The Cochrane Database of Systematic Reviews, 10(10), CD003942. 

This study provides evidence for the professional, institutional, and structural interventions effectiveness. According to the authors, rules and guidelines aim to enhance the teamwork and work role of interdisciplinary teams. Finally, structural interventions aim to evaluate the care provided by increasing staff members’ motivation and capacity to carry out preventative measures. This tool aids medical providers in comprehending their important roles, encouraging teamwork and communication skills, and promoting staff training programs. Adverse drug reactions are a significant contributor to hospital admissions and mortality in primary care. Serious drug reactions, which are typically unpredictable, or medication mistakes may be the cause of adverse outcomes.

Fossum, M., Hughes, L., Manias, E., Bennett, P., Dunning, T., Hutchinson, A., Considine, J., Botti, M., Duke, M. M., & Bucknall, T. (2016). Comparison of medication policies to guide nursing practice across seven Victorian health services. Australian health review: A publication of the Australian Hospital Association, 40(5), 526–532. 

This journal article examines certain medication reconciliation practices that are connected to the seven-health service in Australia’s administration of medications. The regulations cover things like staff permission, labeling injectables and fluids, controlling drug errors, and controlling substance medications and poisons. The paper has outlined how identifying and addressing systemic and human factors—such as stress, disruptions, diversions, exhaustion, and inadequate training—can assist in developing strategies and policies to minimize future errors. The authors contend that guidelines, regulations, and practices can support nurses in securely administering medications. This tool can help nurses be more vigilant and adhere to rules and regulations in an effort to provide patients with the greatest safety measures. Concerns about continuity in leadership and practice surrounding medication management are raised by the disparity in incident management guidelines between organizations. Medication mistakes have previously been linked to a lack of practice standardization. To improve uniformity, the lack of inter-jurisdictional harmonization needs to be addressed. Medical practitioners relocating from one delivery of services to the other may become confused regarding standards as a result of inconsistent standards in medical care, which could raise the likelihood of prescription errors.

Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi Medical Journal, 38(12), 1173-1180. 

The goal of the scholarly article is to examine the most recent scientific data on how various health information systems affect patient care and safety. Additionally, it can lessen human error, ease coordination of care, track progress for a period of time, enhance patient care outcomes, and promotes most effective safety practice. Information technology examples include telemedicine, electronic health records, decision support, computerized medicine systems, and computer-based patient records. This article illustrates how computer technology may be a crucial tool for lowering prescription errors, raising quality of healthcare, and enhancing outcomes for patient safety. It can be concluded that health informatics enhances the safety of patients by lowering prescription errors, lowering negative drug responses, and raising adherence to recommended practices. There should be no question that health informatics is a crucial tool for raising the standard and security of healthcare. Healthcare organizations must exercise caution when deciding which technologies to invest in because research indicates that some of these investments may not significantly improve patient safety results.