NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

Analyzing a Current Healthcare Problem or Issue: Medication Errors

Analyzing Medication Errors

     In  the demanding world of healthcare, medical professionals are responsible for ensuring the safety of patients they encounter. There has been a constant problem with medication errors, some of which can inadvertently cause harm or possible death.  Medication errors include inappropriate dispensing and administration of drugs which causes harmful effects and possible death. As discussed in  the prior assessment, medication errors can be decreased if healthcare workers communicate effectively and respect each other’s professional roles.  Also, efforts have been made to improve the efficacy of medication administration. Efforts such as nurses following the guidelines of the five rights of medication administration, have been in place to decrease medication error. Those five rights include: right drug, right patient, right dose, right route, and the right time to administer medication. This paper is aimed to address the effects of medication errors and to analyze ways in which healthcare professionals can decrease its occurrence. 

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

Elements of the Problem/Issue

     Elements of medication errors include a break of chain of events such as prescription errors, dispensing errors, administration errors, and environmental errors.  Prescription errors may include poorly handwritten scripts from a provider. Dispensing errors may include the wrong dose, or mechanical errors when preparing the medication. Administration errors includes  issues with sound alike look alike medications and failure to follow the five rights of medication administration. According to the World Health Organization (WHO) article in Patient Safety Solutions,  the existence of confusing drug names is one of the most common medication errors worldwide (WHO 2017). Environmental errors include poorly staffed facilities and fear of nurses losing their jobs if they report a medication error. This fear of reporting not only cause a delay in possible treating side effects that may occur but can pose lethal harm to the patient (Dirick, H et al, 2019).

Analysis

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

 As a registered nurse it is important for me to provide the safest quality of care to the patient I care for. It is especially important for me to identify when an error can occur and how to decrease its risk. Administering the wrong medication can have negative effects or cause life threatening events for patients. According to the Journal of Nursing Care Quality, approximately a quarter to a third of medication errors occur at the administration phase, this is the sole responsibility of the nurse to ensure correct medication practices (Armstrong et al, 2017). In addition, a nurse may intervene during collaboration of the interdisciplinary team. If he or she notices a potential error that may occur, it must be addressed immediately and reported. This can be considered an environmental factor that plays a role in medication errors. 

Context for Medication Error

     Medication errors can occur in any healthcare setting.  These settings may include hospital, nursing homes, rehabilitation facilities and physician’s officeWith the vast majority of the aging population with chronic illness and diseases, poly pharmacy can cause an increase in medication errors. 

Population Affected

As people get older, more complex health issues and diagnoses can occur. With complex and chronic diseases on the rise, this patient population are at risk to encounter  poly pharmacy which is the use of multiple drugs to treat a particular illness.  Poly pharmacy is especially common in the older and younger population, and this can place these patients at higher risk for adverse events. Healthcare providers must be prepared to educate this population on the use, side effects, and how a particular drug can affect them. Those with chronic diseases and comorbidities require complex medication management, which include but not limited to, frequent follow up with the prescribing healthcare provider, monitoring of blood levels depending on the medication, and frequent medication review. Pediatric patients are fragile and a dose too big or small can pose potential harm. Pediatric medication doses are reliant on factors such as the child’s age and weight and has a greater risk of harm compare to the adult population.

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

Healthcare professionals need to be very vigilant in providing the proper medication education to these specific groups.  If not taken into consideration, these population can be at risk for adverse effects and potential life-threatening circumstances from a medication error.

Considering Options

It is important to consider that safer medication practices start with safer primary care. Most of preliminary medication and treatment are initiated in primary care settings so we must be collaborative in paying attention to how medications will alter treatment management in a hospital setting and create a seamless effort in transitional care back to primary care settings. While paying attention to what changes in medication management this is how we can prevent medication errors from occurring such as changes in dosages, frequency, and discontinued medication.

It is also important to consider factors in a work environment that may alter medication practices or pose a risk to medication errors from occurring. In a hospital setting, nurses often work in pressured times and increased workload (Wilson et.al 2017). Distractions and interruptions can occur from all levels of care to the acuity of the patient. Insufficient resources may also be a contribution to medication errors while dispensing or administering medications to patients. Issues with physical work environment such as loud working areas ,understaffed ratios, and unavailable management can pose a risk to not being able to identify a medication error from occurring. You must also consider the knowledge level of the patient and healthcare provider. 

Solution

  Considering that administration phase is one of the top causes of medication errors, implementing a system wide solution such as, automated prompting of the five rights of medication prior to medication administration can significantly decrease the risk of an error from occurring. When nurses ignore the five rights a breakdown in the process can include, the wrong patient, administering the wrong dose, administering medication at the wrong time, and giving meds via the wrong route. Instilling these approaches will allow for safer medication administration and decreases errors in all healthcare settings that uses automatic prompting of the five rights. Although this can create seamless results, when healthcare facilities don’t have enough resources to obtain electronic health records this can be considered a barrier that can eliminate medication errors.

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

Implementation

 In the advance world of healthcare technology, electronic health record is becoming more accessible to all healthcare providers. A systemic approach to combatting prescription errors can include, doctors using E- prescription instead of handwritten scripts. 

Labeling Look alike-sound alike medication is another way of preventing medication error from occurring. This will alert healthcare providers of potential drugs that may be easily mistaken for another. Healthcare provides must provide education to patients and encourage them to be involved in their healthcare. Providing educational resources on new medication and having care conferences with other members of the family are important aspect when patient is being discharged from a healthcare facility. Electronic prompting of the “five rights” prior to medication administration can also be an effective solution to decrease medication errors. This will allow for nurses to have a safety check prior to administering medication. The solution mentioned will be effective if all healthcare providers work together collaboratively and utilize the recourses available to decrease medication errors.  

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

Conclusion

          Medication errors involve a collaborative approach within any healthcare setting. A medication error can compromise patient safety and lead to adverse events and poor outcomes. Medication errors can occur at all levels of the administration process including dispensing, transcribing, and administering. It can also be affected by the work environment. Implementing. a system approach by adapting to an EHR with five rights prompting, alleviating stressors at work, and instituting look alike sound alike protocol will allow for safer medication administration in all healthcare settings. In addition, nurses have an ethical decision to make when an error occur. Nurses are able to recognize medication errors but are reluctant to report them (Dirick, H et al, 2019). With all things to consider as mentioned above, recognizing when an error occurs, events leading up to it, and factors that play a role will improve efforts made in decreasing the likelihood of medication errors. 

NHS FPX 4000 Assessment 3 Analyzing a Current Health Care Problem or Issue TS

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References

Armstrong, G. E. , Dietrich, M. , Norman, L. , Barnsteiner, J. & Mion, L. (2017). Nurses’ 

Perceived Skills and Attitudes About Updated Safety Concepts. Journal of Nursing Care 

Quality, 32 (3), 226-233. doi: 10.1097/NCQ.0000000000000226.

 Amanda Jane Wilson, Lorinda Palmer, Tracy Levett-Jones, Conor Gilligan & Sue 

Outram (2016) Interprofessional collaborative practice for medication safety: Nursing, 

pharmacy, and medical graduates’ experiences and perspectives, Journal of 

Interprofessional Care, 30:5, 649-654, DOI: 10.1080/13561820.2016.1191450

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

 World Health Organization (2017). WHO global patient safety challenge: Medication without harm. Geneva, Switzerland: World Health Organization.

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