Phillip January 8, 2024 No Comments

Capella 4020 Assessment 1

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 preventable adverse events that must be controlled effectively within a healthcare organization. Medication errors are one of the major factors that impact patient safety. According to the World Health Organization, more than half of preventable harm in hospitals is caused by medication errors (WHO, n.d.). To prevent patient harm and further implications of high costs and increased length of stay at hospitals, it is crucial to implement safe medication management strategies to enhance the quality of care and patient safety. Nurses are primary caretakers who are actively involved in administering medications, their role in safe administration can be rendered effectively that ensures patient safety.

Factors Leading to a Specific Patient-Safety Risk 

Reminiscing a recent medical error adverse event at Tampa General Hospital, 45-year-old Hannah was admitted for post-surgery recovery of the appendix. Her doctors have prescribed her painkillers, including morphine, ciprofloxacin, and heparin. When nurse Olivia is about to dispense medication from the automated medication dispensing system, she takes a phone call. While at the same time, the automated dispensing system presents some glitches and dispenses the wrong medication. Olivia, being momentarily distracted due to a phone call, administers a double dose of heparin instead of morphine. This causes significant bleeding in the patient. The patient became hemodynamically unstable, which led to a crash situation. The nurse, upon recognizing the condition, announces a rush call. Although Hannah was reverted, she underwent various complications and extended her recovery period. The patient and her family encountered traumatic events, high healthcare costs, increased length of stay at the hospital, and distress. 

Several factors contribute to specific patient safety risks of medication administration. These factors include a lack of education on medication administration, poor maintenance of technology-based medication management, and external distractions. When the nurses are not adequately educated and trained on the safe and mindful medication administration, they may administer medicines with inappropriate techniques (Vaismoradi et al., 2020). One study states that 62.1 % of nurses lack training in safe medication administration, leading to various medication administration errors, eventually causing morbidities and increasing mortality rates (Wondmieneh et al., 2020).

Capella 4020 Assessment 1

Moreover, technological methods used for medication management require timely maintenance to avoid glitches, another factor causing medication errors. This leads to the risk of patient harm due to unsuitable dispensing or display of prescribed drugs (Alzahrani et al., 2023). Lastly, external interruptions during the medication administration process can divert nurses’ attention, resulting in minor or significant medication errors impacting patient safety. External interruptions can be taking phone calls, blabbering with colleagues, or lacking mindfulness due to stress or fatigue while administering medications. About 18.8 % of medication errors are informal bedside communication that diverts nurses’ attention to the administration process (Manias et al., 2021). Thus, it is crucial to address these factors to preserve patient safety. 

Evidence-Based Solutions to Improve Patient Safety 

 To improve patient safety and promote safe medication delivery, it is crucial to implement the best practice solutions substantiated by evidence. Moreover, medication errors incur massive costs due to litigation expenses and additional treatments. Medication errors are responsible for causing $4.2 billion in costs annually, which makes up 1% of total health expenditures worldwide (WHO, n.d.). Therefore, it is equally imperative to implement those solutions that promise cost reduction. One of these evidence-based solutions is training nurses on safe medication administration, where they learn about medication administration techniques and standardized protocols, preventing medication errors due to inadequate knowledge. Additionally, training nurses on maintaining professional behavior and attitude avoiding informal bedside conversations and mindlessly talking on the phone during medication administration can help avoid medication errors (Manias et al., 2020).

This will promote patient safety as the nurses administer medication carefully. Another strategy involves barcode medication administration (BCMA) by which accurate medication can be delivered. BCMA enables matching the medication’s barcode with the patient’s wristband to overcome medication errors due to wrong medication administration (Owens et al., 2020). Training nurses and using BCMA technology can improve patient safety and reduce costs incurred by medication errors and required procedures to treat those errors. One study shows the cost-effectiveness associated with the implementation of BCMA technology for medication administration error prevention. Implementing BCMA resulted in a reduction of 102,210 MAE at the cost of  €1,808,600 annually, which corresponds to a cost-effectiveness ratio of €17.69 per prevented MAE (Jessurun et al., 2022).

Capella 4020 Assessment 1

When nurses utilize this technology for administering medications to patients while following the protocols on medication administration, the chances of medication errors will be reduced. This will lead to the prevention of further treatments associated with medical errors and ultimately reduce costs associated with them. Furthermore, the resources will be allocated to other treatment procedures instead of medical error treatments, which will also lower the healthcare cost burden on the organization. Patients will not have to spend extra on treating problems associated with medical errors, such as surgical interventions, emergency medication needs, and increased length of stay at the hospital. Moreover, litigation expenses will be avoided when these strategies are implemented. 

Care Coordination by Nurses to Improve Patient Safety 

Nurses are considered the best collaborators within healthcare systems which can result in improved patient safety in terms of medication administration while reducing costs associated with medication errors. There are multiple ways by which nurses can deliver coordinated care in medication administration and foster a culture of care and patient safety. Nurses must use a medication reconciliation strategy to collaborate with healthcare providers in case of misunderstanding and existing enigma (Uhlenhopp et al., 2020). In our previously mentioned scenario, nurse Olivia should have looked at whether the medication she was delivering matched the prescription record. This could have prevented Hannah’s safety risk to Hannah and improved her safety.

Moreover, nurses can implement protocols on the “Five Rights of Medication Administration” and double-check the medication before delivering it to patients. These Five Rights of Medication Administration comprise the right medicine, the right route of administration, the right dose, the right patient, and the right time (Hanson & Haddad, 2022). Olivia should have followed this rule while administering Heparin to Hannah which could have prevented the onset of this error. Furthermore, ongoing education and interdisciplinary collaboration can freshen up nurses’ memory of rules to implement while administering medications (Uhlenhopp et al., 2020).

Capella 4020 Assessment 1

For instance, in the scenario above, Olivia could have collaborated with physicians or fellow nurses on medication management for Hannah as she came for post-surgery recovery requiring intricate and attentive care. This can be done by providing monthly refresher sessions to nurses to ensure they develop professional behavior and take patients’ health as the sole purpose of their nursing care. By rigorously following the ‘Five Rights of Medication Administration,’ nurses can drastically reduce the chances of medication errors. As the nurses will strictly abide by these principles, the patients will acquire correct medication and no further treatments will be required as needed if wrong administration of medication is delivered. This will ultimately save costs for both the organization and patients. Lastly, costs associated with legal actions due to medication administration errors will be prevented, further reducing costs.  

Nurses’ Coordination with Other Stakeholders

Nurses can engage with critical stakeholders to coordinate effectively, which can drive quality and safety improvements in medication administration. First, nurses can collaborate with healthcare providers such as physicians who prescribe medications and pharmacists who dispense medication accurately. Through interdisciplinary collaboration with these stakeholders, nurses can deliver consolidated care by administering medications accurately and minimizing potential medication errors.

Furthermore, nurse-patient engagement is necessary to improve patient safety for medication administration (Parr et al., 2020). By guiding patients on safe and correct medication self-administration and promoting medication adherence to prescription, nurses can play a vital role in avoiding patient-driven medication administration errors and improving their health outcomes, resulting in enhanced patient safety. These stakeholders are closely relevant to medication administration, and their engagement with nurses is crucial as healthcare providers are direct prescribers, and patients are direct recipients of medications being administered.

Conclusion

Medication error due to administration is a global issue impacting patient safety. The recent patient’s experience of facing medical error due to wrong administration by nurses showed a pressing need for quality and safety enhancement in Tampa General Hospital. Factors like inadequate trained nurses, poor attitude during medication administration, and lack of appropriately maintained healthcare information technologies. Evidence-based solutions to improve patient safety and reduce the costs of medical errors include conducting training on medication administration, BCMA technology use, and medical reconciliation. Nurses can coordinate care by using these strategies and implementing medication administration protocols. Furthermore, they must collaborate with patients and healthcare providers to improve patient safety and reduce medication errors.

References

Alzahrani, A. A., Aledresee, T. M., & Alzahrani, A. M. (2023). Issues faced by pharmacy technicians while maintaining automated dispensing cabinets and how to overcome them in the national guard health affairs in Riyadh: A qualitative study. Cureus. https://doi.org/10.7759/cureus.42210 

Hanson, A., & Haddad, L. M. (2022). Nursing rights of medication administration. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560654/

Jessurun, J. G., Hunfeld, N. G. M., van Dijk, M., van den Bemt, P. M. L. A., & Polinder, S. (2022). Cost-effectiveness of central automated unit dose dispensing with barcode-assisted medication administration in a hospital setting. Research in Social and Administrative Pharmacy, 18(11), 3980–3987. https://doi.org/10.1016/j.sapharm.2022.07.006  

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1), 1–29. https://doi.org/10.1177/2042098620968309 

Manias, E., Street, M., Lowe, G., Low, J. K., Gray, K., & Botti, M. (2021). Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: A retrospective clinical audit. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07033-8 

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing, 46(6), 884–891. https://doi.org/10.1016/j.jen.2020.07.004

Capella 4020 Assessment 1

Parr, J. M., Teo, S., & Koziol‐McLain, J. (2020). A quest for quality care: Exploration of a model of leadership relationships, work engagement, and patient outcomes. Journal of Advanced Nursing, 77(1), 207–220. https://doi.org/10.1111/jan.14583  

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15. https://doi.org/10.3390/ijerph17062028 

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(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0

WHO. (n.d.). What is a medication error? https://cdn.who.int/media/docs/librariesprovider2/country-sites/medication-error-wpsd-final.pdf?sfvrsn=e5853e2a_1&download=true

WHO. (n.d.). WHO launches global effort to halve medication-related errors in 5 years. https://www.who.int/news/item/29-03-2017-who-launches-global-effort-to-halve-medication-related-errors-in-5-years#:~:text=Globally%2C%20the%20cost%20associated%20with