Administering drugs is one of the essential tasks of healthcare professionals. It is a complex procedure that involves “counting, calculating, measuring, mixing and ensuring that the right person receives the right medicine in the right dose, at the right time, by the right route, and for the right reason” (Lapkin, Levett-Jones, Chenoweth, & Johnson, 2016, p. 846). Because of its complexity, it sometimes results in medication errors, especially in elderly patients who have multimorbidity and chronic conditions and take multiple medications (Kavanagh, 2017). Medical errors result in various adverse events, endangering patients’ health and reducing the quality of care. This paper aims to answer the question of what could be changed within the healthcare environment to improve patient safety and reduce the risk of adverse events because of medication errors.
The Causes and Clinical Outcomes of Medication Errors
St. Anthony Medical Center is a large hospital located in Minneapolis. The hospital needs a change to improve patient safety by reducing the number of medical errors. The data for justifying the need for change includes St. Anthony Medical Center’s performance review regarding medical errors and an overview of the negative effects of such errors. As is evidenced by Table 1, the hospital has sub-optimal outcomes in terms of medication errors made, especially transcription errors. Transcription errors are those related to transferring the information from prescriptions incorrectly or incompletely (Riaz, Riaz, & Latif, 2017). The causes of these errors include misinterpreting phone orders, illegible prescriptions, and increased duties hours of nurses (Riaz et al., 2017). St. Anthony Medical Center should reduce the rate of transcription errors, but it would also benefit from decreasing the number of other medication errors. Common reasons for other medication errors are ineffective interprofessional collaboration, distractions, understaffing, nurses’ lack of medication knowledge and calculation skills, and a fear of reporting (Kavanagh, 2017). Therefore, St. Anthony Medical Center should consider strategies that would improve the working environment in a way that would address the causes of medical errors.
Table 1. Types of medication errors made in St. Anthony Medical Center during the past year. Source: “Vila Health: Using Evidence to Drive Improvement” scenario.
|Forgot to Discontinue||0||3||2||0||0|
|Wrong Dose (over)||22||17||23||14||10|
|Wrong Dose (under)||8||7||8||7||5|
|Forget to Order||23||17||26||21||15|
St. Anthony Medical Center should implement change to reduce medication errors because its sub-optimal results are an indicator of insufficient patient safety. Medication errors may lead to such adverse outcomes as longer hospital stays, litigation, higher rates of morbidity and mortality, and increased costs of healthcare (Kavanagh, 2017). In addition, nurses are often the only ones blamed for medication errors, which causes them to feel guilty and incompetent, as well as unwilling to report errors (Kavanagh, 2017). As a result, St. Anthony Medical Center will benefit from the suggested change in terms of patient safety, equitable care, and the well-being of the healthcare personnel.
Proposed Change Strategies
To achieve the desired outcomes in terms of medication error rates, the hospital should consider such strategies as educational interventions, interruption management interventions, and using technology support, such as barcoding. Educating nurses in the field of pharmacology and dose calculations increases their knowledge of medication administration, but this strategy is effective only if it is combined with other risk-management strategies (Lapkin et al., 2016). Interruption management includes changing the healthcare environment: placing medications not far from patients, using “do not disturb” signs, and arranging quiet zones for preparing medications (Lapkin et al., 2016). The use of barcoding technology ensures that patients receive the right dosages of the appropriate medications (Riaz et al., 2017). Apart from these methods, the hospital should involve pharmacists in collaboration with nurses and healthcare professionals. It has been found that pharmacists’ assistance with patient education, change of dose, or the choice of medication decreased the risk of medication errors (Riaz et al., 2017). The proposed strategies can be applied to achieve the desired outcomes if the healthcare team understands the importance of medication error reduction, works in collaboration, and adheres to the strategies.
To ensure that the change strategy is successful, the healthcare team should develop a solid step-by-step plan. Trakulsunti and Antony (2018) have found that the Lean Six Sigma framework can help healthcare organizations implement change to reduce medical errors. Lean Six Sigma divides the process of change implementation into five stages: define, measure, analyze, improve, and control (Trakulsunti & Antony, 2018). Researchers found that taking these consecutive steps helped healthcare organizations decrease error rates, increase patient satisfaction, enhance employee morale and interprofessional relationships, and improve productivity (Trakulsunti & Antony, 2018).
Expected Outcomes of the Proposed Strategies
The proposed strategies will positively affect all aspects of the Quadruple Aim. First, reduced medication errors resulting from the proposed strategies will improve healthcare quality and safety by decreasing the number of adverse events. Secondly, reduced medical errors will boost the hospital’s performance, which will have a positive impact on community health. Thirdly, the strategies will lead to a decrease in adverse events, which will reduce the cost of healthcare. Finally, change implementation will positively influence healthcare providers. Interprofessional collaboration, which is required for successful change implementation, will increase the value of pharmacists and enhance the well-being of nurses who often feel fatigued and guilty of errors (Wilson, Palmer, Levett-Jones, Gilligan, & Outram, 2016). The involvement of various healthcare professionals in medication administration will improve interprofessional relationships, reduce workloads, and enhance productivity.
Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159-165.
Lapkin, S., Levett-Jones, T., Chenoweth, L., & Johnson, M. (2016). The effectiveness of interventions designed to reduce medication administration errors: A synthesis of findings from systematic reviews. Journal of Nursing Management, 24(7), 845-858.
Riaz, M. K., Riaz, M., & Latif, A. (2017). Medication errors and strategies for their prevention. Pakistan Journal of Pharmaceutical Sciences, 30(3), 921-928.
Trakulsunti, Y., & Antony, J. (2018). Can Lean Six Sigma be used to reduce medication errors in the health-care sector? Leadership in Health Services, 31(4), 426-433.
Wilson, A. J., Palmer, L., Levett-Jones, T., Gilligan, C., & Outram, S. (2016). Interprofessional collaborative practice for medication safety: Nursing, pharmacy, and medical graduates’ experiences and perspectives. Journal of Interprofessional Care, 30(5), 649-654.