Enhancing Quality And Safety

Enhancing Quality And Safety

Medication administration errors can occur as a result of any of the five rights (right patient, medication, time, dose, and route). A medication error is defined as “any preventable event that may cause or lead to improper medication use or patient harm while the medication is under the control of a healthcare professional, patient, or consumer” by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). (Márquez-Hernández et al., 2019, p. 02) Medication mistakes are unquestionably expensive for patients, families, employers, hospitals, healthcare providers, and insurance companies.

Medication Errors and Their Causes

Medication errors can occur as a result of individual lapses and slips, but they can also occur as a result of system-level failures such as understaffing, human factors issues (e.g., poor process or equipment design), and other latent conditions. Interruptions/distractions, a lack of knowledge and experience, and transcription errors can all lead to errors. Because of a lack of funding in these areas, low-income areas are especially vulnerable to medication errors. A study conducted by M. Thirumagal et al. found that in a specific low-income area, “Among 400 patients, the total number of errors found was 142 (35.5%), with 130 (32.5%) errors related to prescribing and 12 (3%) errors related to medication administration. There were 115 patients (28.8%) who had at least one medication error.” (M. Thirumagal, 2017, p. 687) Prescribing errors are defined as violations of the five medication administration rights.

Best Practices for Avoiding Medical Errors

Implementing an automated medication or barcode medication system is one of the most common solutions to combating medical errors. This improves the medication administration system by providing a simpler, more organized method of deploying medication. Barcode medication administration (BCMA) technology can reduce medication errors by preventing mistakes such as administering the wrong dosage or drug to the wrong patient. “A study in a teaching hospital found that the use of BCMA technology reduced the rates of incorrect medication by about 57%, incorrect dosage by nearly 42%, and omitting or incorrectly charting medication given by 80.3%.” D. Baiden (2018, p. 02). BCMA has its own risks, such as the risk of compromising patient information, but it has been shown to be one of the best solutions to medication errors. Near-miss event reporting has been shown to aid in the reduction of some of the errors associated with BCMA.

A robust patient safety program must include near-miss event reporting and analysis. Near-miss event analysis allows an organization to identify real and potential hazards in a process before an event causes harm to a patient. In terms of near-miss event reporting and analysis, healthcare is catching up to other industries, such as aviation and nuclear energy. Reporting, but more importantly, analyzing near-miss events can lead to process improvements and reduce the risk of patient harm.

The Pennsylvania Patient Safety Authority tells the story of how Blue Mountain Health System reduced barcode-workflow events by 53% between 2014 and 2016 in a case study. (Hospital Peer Review, p. 02, 2018). The health system used near-miss event review and analysis to improve its BCMA process, which was made possible through a collaborative effort with the Authority’s analysts and patient safety liaison.

The article explains how reporting near-miss events can lead to other useful tools, such as the Good Catch ratio. This is useful because, in addition to the overall near miss-to-Serious Event ratio, it can be used to assess BCMA reporting practices. The Good Catch ratio compares the number of close calls to the number of serious incidents. “A higher Good Catch ratio indicates a safety culture that values identifying and reporting hazards before harm occurs.'” (Hospital Peer Review, p. 01, 2018).

How Nurses Can Assist in Care Coordination

Nurses owe it to their patients and themselves to learn how to avoid and learn from mistakes. These errors are not limited to nurses; it is the responsibility of all healthcare professionals to keep patients safe. Most employees are afraid to report errors at work because they are afraid of the repercussions. Nurses are normal employees, so they should be concerned about the consequences. Nurses must overcome their fear of reporting medication errors in order to help prevent future errors. Distractions and Interruptions are normal in the work environment, but for nurses, these distractions can lead to medication errors. This is why nurses must remain vigilant and aware of their surroundings.

Nurses are one stakeholder who can assist other nurses with medication errors. They can contribute to the development of a safe culture and an environment conducive to learning and growth. This is important for nurses because it facilitates discussions about the changes that need to be made and allows nurses to receive advice from their peers. In my own experience, I have seen new nurses seek advice and guidance from their peers, and those who do tend to make fewer mistakes than those who do not. As a nurse leader, I strive to foster an environment in which my team members can come to me with questions or problems. I use my personal experience and knowledge to offer as much assistance as possible.

Conclusion

The importance of near-miss event analysis in preventing patient harm cannot be overstated in healthcare. BCMA has been shown to be an effective tool in the fight against medication errors. The near-miss analysis is a valuable source of information about patient safety hazards and system weaknesses, as well as identifying patient safety priorities and tracking progress on safety and quality-improvement initiatives. Using the lighthouse metaphor, near-miss event reporting and analysis assist organizations in keeping patients safe as they navigate the healthcare system.

References

Baiden, D. (2018). Factors affecting the impact of barcode medication administration technology in reducing medication administration errors by nurses. Canadian Journal of Nursing Informatics, 13(1) Retrieved from http://library.capella.edu/login?qurl=https%3A%2F %2Fsearch.proquest.com%2Fdocview%2F2313385379%3Faccountid%3D27965

Márquez-Hernández, V.,V., Fuentes-Colmenero, A., Cañadas-Núñez, F., Muzio, M. D., Giannetta, N., & Gutiérrez-Puertas, L. (2019). Factors related to medication errors in the preparation and administration of intravenous medication in the hospital environment. PLoS One, 14(7) doi:http://dx.doi.org.library.capella.edu/10.1371/journal.pone.0220001

Study near-miss barcode medication errors to prevent worse events. (2018). Hospital Peer Review, 43(5) Retrieved from http://library.capella.edu/login?qurl=https%3A%2F %2Fsearch.proquest.com%2Fdocview%2F2028829305%3Faccountid%3D27965

Thirumagal, M., Ahamedbari, M. A. R., Samaranayake, N. R., & Wanigatunge, C. A. (2017). A pattern of medication errors among inpatients in a resource-limited hospital setting. Postgraduate Medical Journal, 93(1105), 686. doi:http://dx.doi.org.library.capella.edu/10.1136/postgradmedj-2017-134848

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The goal of creating a nursing concept map is to create a plan of care for a child with bronchiolitis. The nursing interventions would reflect the underlying respiratory syncytial virus with patent ductus arteriosus (PDA) history.

Competency

Apply the foundations of pediatric nursing when caring for clients with health alterations.

Scenario

You are working in a large urban pediatric clinic after hours.

A mother brings her 6-month-old daughter, Vivi Mitchell, to the clinic for rhinorrhea, congestion, fever, and cough. Upon assessment, you identify the child has to wheeze upon auscultation and on inspection, you identify retractions.

• The child is in less than the 10th percentile of weight and has a cardiac history of Patent Ductus Arteriosus (PDA).
• Born at 36 weeks gestation.
• The mother states this child doesn’t go to daycare but her two other children ages 2 and 3 do attend daycare.
• T- 102.1 HR 140 RR 40 BP 83/58 Pulse ox 96%
• A swab for the respiratory syncytial virus (RSV) is positive.

Doctor orders – Nasal bulb suction and saline drops PRN, Tylenol 15mg/kg Q4 PRN for fever, Albuterol nebulizer in office, and push to fluids as tolerated.

After the albuterol neb treatment, respirations are 36, and oxygen saturation is 100%. Wheezing has diminished. Mom is an ER nurse and the doctor feels comfortable that she has a nebulizer at home and can return to the pediatric after-hours or ER