Introduction
One of the major clinical issues in every health care organization is medication errors. The expression “medication errors” describes the harm caused to a patient due to inappropriate medical care. An adverse event indicates an undesirable clinical outcome caused due to the medical care not because of the underlying disease. The medical errors include incompatible blood products usage, erroneous dispensing and medication administration. Medication errors can at times result in adverse health resulting in death. It was estimated that every year approximately 1.5 million medication errors occur . These errors range from medication overdose to the administration of wrong medicine to medication omission. Such medication errors were reported to account for 3 billion dollars in the United States, annually. Additionally, surveys have also shown that medication errors lead to the death of 30,725 patients in 2011, which was later found to increase by 47.8 % in 2012 causing 45,421 deaths . Considering the health care costs, loss of income, household productivity loss and disability, the total expenditure of such medication errors are estimated. Dracup (2003) had reported that approximately 70 % of theses medication errors can be prevented with additional care and improve the awareness of the nursing staff. On the other hand, the Center of Disease Control and Prevention, estimated that 40% of these expenses could be prevented if the proper practice was done in the hospitals by the healthcare providers .
In the health care settings, the medication errors have emerged as one of the biggest critical issues. Upon surveying, Katz (2005) reported that almost all health care organization and professionals accept and are aware of this issue but none could address ways to tackle this medical issue. In the health care profession, any divergence from the established policies, best practices and/ or procedures for administration of medicines to the patients has been defined as medication errors . Today, it is considered as a serious issue during the clinical practice. Any kind of adverse events are reported to the administration and are registered in the system known as the Incident Response Improvement System (IRIS) . In most cases, medication errors are not reported by the nursing professionals due to the threat of getting punished. This, in turn, prevents the health care organization from taking necessary actions to reduce the prevalence of medication errors. The increasing prevalence of medication errors is an increasing and serious threat to the health of the patient population. Therefore, there is an urgent need to plan effective interventions to prepare nursing staff to be more alert, aware and effective in providing best possible care to their patient by preventing medication errors.
Clinical Issue
During one’s clinical practice, administering medications to the patients is one of the major tasks of the nursing professionals. The patient blindly trusts the nurses and thus the responsibility on the nurse’s shoulder is huge. However, literature review indicates that prevalence of such error is high and reporting of such errors is rare. This makes research difficult and thus coming up with an effective solution becomes difficult . Thus, it is necessary to increase awareness and educate nursing professionals in terms of medication administration and management. This will enable them to identify the errors prior to their occurrence.
Importance
It is commonly believed that nursing professionals are solely responsible for such errors. However, it is important to focus on the causes of medication errors in order to eliminate the causes during nursing practice and reduce the prevalence of errors . When a health care organization or the administration or the nursing leader fails to address such clinical issues, they eventually miss out on the opportunity to improve their clinical outcomes. Therefore, such miss out can tremendously affect the health and satisfaction of the patient population, disrupt the normal functioning of the health care system, hugely affect the reputation of the organization and increase workload and stress among the nursing staff.
Patient Population
Researchers argue that the paediatric population are at a higher risk than the elderly and vice- versa. Experts claim that the paediatric population is at higher risk because of the drug doses which involves calculations based on the weight, decimal points, and fractional dosing. Additionally, most medication prescribed to this population is mostly packaged for adults and thus, the dosing differs for the children. Unlike the adult population, paediatric population are unaware of the drug being administered or are too small to communicate their issues and are thus at higher risks. Some have pointed out that approximately 11.1% of this population are victims of medication errors. Similarly, researchers pointed out that the adult population who are of age 60 or above are also the most common victims . This population mainly includes older patients with serious health complications, or are taking high- risk medications, or are administered with multiple medications, or are transferred from community care to hospital care set up. Upon reviewing, it is evident that patients, be it paediatric or geriatric, it is the lack of communication, incompetency, and illiteracy that increases the prevalence of medication among these patient population.
Additionally, experts have also reported that serious medication errors can also occur as a result of cultural differences between the measuring system and vocabulary. Furthermore, understanding the numerical information of the medications prescribed can also lead to confusions such when spoken many numbers in English sounds similar. The risk determination process is often reliant on complex equations which include genetic history, medical history, health behaviours and exposures. Such risks are also highly influenced by the social, political and cultural practices, which varies between different cultural groups. Additionally, some cultural beliefs and values often restrict the patients from understanding and performing upon informed about potential risks. In culturally and ethnically diverse countries, health care professionals come from different background, which can again exacerbate communication issues. Cultural differences act as a huge barrier in communication between nursing professionals, clinicians, and patients. Such cultural values beliefs can tremendously influence the proposed plan to minimize medication errors in health care organization .
Proposed Solution
Medication errors are common in every hospital set up and most don’t get reported because of the threat of being penalized. Thus, there is an urgent need for interventions that would enable the nursing professionals to trust the organization so that they themselves can report their mistakes and thereby help to find solutions to the blunders. Based on the published literature, it is evident that most sentinel events and serious medication errors occur due to lack of active communication between nurse – physician, nurse- pharmacist, nurse- nurse and nurse- patient. Other reasons include distrust among professionals, lack of pharmacological knowledge , work overload, stress , workforce shortage and inappropriate practice setup. These factors have severe negative impact on the health and safety of the patient populations.
Therefore, this Capstone project proposes an intervention that would firstly educate the new nurse graduates about the organizational culture and practices and encourage them to increase communication amongst them. This intervention will also include face- to- face discussion session where all nursing professionals can share their experiences and the ways they resolved the critical situation. This practice would readily increase awareness among nursing professionals and would keep them alert when administering medications. The third step of this intervention would be to provide compulsory training to all the nursing professionals where they will be educated about different medications and their calculations, risk management, identification of errors and different policies and recommendations to prevent medication errors. Such training would keep nursing professionals updated and increase awareness about the new drugs.
The intervention will also include simulation training where the nursing professionals will be practicing on dummies before they start dealing with live patients. This would help in building confidence among nursing professionals and instill risk management and critical thinking skills in them. Lastly, rewarding the clinical winners or early learner, this would encourage the nursing professionals to give their best efforts during their practice. This would also enhance communication, and teamwork among the professionals, which would further assist in practicing “No Blame Culture” in the organization. Incorporation of these methods/ practices in an organizational set up will effectively help in reducing the medication errors among the nursing professionals as these steps would not only educate the nurses about different cultural practice and increase their awareness towards different drugs and steps to be taken in a critical situation but will also encourage them to accept their faults, volunteer and build confidence in them.
Goals
The main objective of this evidence- based research paper is to prepare a Capstone Paper that attempts to strategize ways minimize the prevalence of medication errors in a health care organization. The main goal is to execute an educational intervention to corroborate proficiency among nurses while administering medication and also to encourage nursing professionals to practice “No Blame Culture” within the organization as this would persuade them to share their knowledge with other professionals. This practice would also create awareness among the professionals and teach them to manage the critical situation when medication errors occur by mistake. Additionally, this Evidence- based Capstone project will help the nursing professionals in determining whether implementation of these educational and simulation strategies would in reality increase the efficiency and awareness of the Practical Nurses, New Graduate Nurses and Registered Nurses who play a major role in administering medications to their patients. The objective of this Capstone project will act as a guideline for the nursing professionals and health care organization to maximize the patient satisfaction and decrease their duration of stay in the hospitals by minimizing the medication errors.
The aims of this Capstone project is divided into five parts: 1) educating nursing professionals about the organizational culture and practices to reduce the communication gap, 2) face- to- face discussion session for all nursing professional, in order to share experiences, 3) educating professionals about pharmacological drugs and calculations of the drugs to be administered to enable appropriate drug delivery and increasing awareness, 4) simulation training to build confidence and prevent incidence of medication error, and 5) rewarding the champions to encourage nurses to work effectively and exercise “No Blame Culture”.
Out of all the five parts, simulation training and educating nurses about organizational culture and practices are the short- term goals of this project, while the remaining three are the long- term goals. The simulation training fall under the short term goals as the nursing professionals will be subjected to this training before they start practicing in the clinical setup. This training is mostly to boost the confidence in the nurses so that they can effectively and efficiently provide the best possible care to the patient population. It additionally trains the nurses for the worst case scenarios. The second short- term goal of educating the professional about organizational culture and practices enables the professionals to be aware of the policies and rules followed in their workplace. This would help them in narrowing down the communication gap between them and their patients and their colleagues Both these goals are considered to be short- term because they will be provided only once in the beginning which would instill the cultural values and beliefs in the nurses prior to the commencement of their clinical career.
On the other hand, the remaining three are considered to be long- term goals because these process needs to be practiced over and over again to keep the nurses updated about the new developments in the field and at the same time increase their competencies by challenging them to perform better. Additionally, face- to- face interactions creates time- to- time awareness in them to practice safe drug administration and steps they can take in a critical scenario. Successful implementation of these strategies will help the nursing professionals to effectively reduce the risks of medication errors during their clinical practice. The attainment of these goals can be identified by monitoring the occurrence of the medication errors in each unit monthly or annually. The data obtained would reflect whether these interventions are effective enough to help them reduce the prevalence of medication errors.
Barriers
Nurses themselves come from a diverse background and in daily practice, they treat diverse patient population. The diverse patient population have their own cultural beliefs, values, and some turn out to be illiterate or have little proficiency in English. The Joint Commission has also regarded illiteracy, limited proficiency in English and cultural barriers as “triple threat”, which affects the communication between patient- nurse or nurse- nurse or physician- nurse. Such threats can become one of the major barriers when implementing the interventions proposed above in a health care setup. However, this barrier can be easily overcome by enabling the nurses to practice teamwork and assign nurses who belong to the same culture as that of the patient to promote effective communication between the two. Another way to overcome the barrier would be by using signs and instructions which would be easily understood by the patients irrespective of the communication gap. This would help in minimizing the medication error as there would be effective communication between the nurse- client and client will be provided with necessary education about the drugs administered. Another potential barrier than can arise while implementing each of the above- mentioned interventions would be the lack of skilled professionals/ faculty to conduct these interventions. The nursing shortage has been reported as one of the major concerns worldwide. With the growing elderly population, the numbers of skilled and experienced nurses are also decreasing and thus a severe lack of skilled professionals has been also reported. Lack of skilled and experienced nursing leader could negatively influence the implementation of these interventions because the new graduates or the existing nurses with little skill would have no one to consult. Therefore, it becomes essential for the health care organizations to arrange for senior staffs who can efficiently conduct this educational evidence- based training programs for the new nurses. Simulation training programs needs experienced teachers so that one can use innovative methods to teach the nurses and put them in critical scenarios to enable them to practice risk management and critical thinking to resolve serious and critical issues.
Benefits
The proposed interventions in this Capstone project are designed only after thoroughly scrutinizing and identifying the actual and potential risk factors that lead to medication error. For decades, nurses are the ones who have been blamed for the occurrence of medication errors, however, now researchers believe that it is not just the nursing professionals but there other critical factors that play a major role in medication errors such as communication errors, pharmacological errors, lack of knowledge and literacy, lack of teamwork, lack of critical thinking and risk management, practicing blame game, etc. These factors appear to be minute but are a potential risk factor which majorly influences nurses during their practice and thereby leading to medication errors. Therefore, this Capstone project takes an initiative to focus on these minute issues and design interventions accordingly.
The proposed educational intervention is divided into five parts. Each of these five parts concentrates on achieving the same goal which is: building self- confidence, increasing awareness, instilling critical thinking and risk management skills and increasing knowledge and skills of the professional nurses. The outcomes of these interventions will indirectly benefit the diverse patient population as well. The patient population will receive the required and necessary attention from the nursing professional. Additionally, simulation training would help the nursing professional to confidently administer the right doses of medication via the right route at the right time, thereby enabling faster recovery of the patient population. Educating nursing professionals about cultural competency would help them effectively interact with the patient population by respecting their values and beliefs and in case of trouble, effective teamwork would help them educating the patient and solving the issues. In addition, practicing “No Blame culture” will further help the nursing professionals to volunteers all by themselves and share their experiences during the face- to- face sessions, which would further help the organization to keep a track of the type and rate of medication errors. Effective monitoring will help the health care organization to not only take necessary steps during critical situations or minimize the medication errors but will also help them to win patient’s trust and satisfaction by providing best possible care to the diverse patient population. Implementation of such interventions by nursing professionals in an organization will do a dual benefit to both the nursing professionals as well as to the diverse patient population. Minimizing education errors would reduce patient’s length of stay in the hospital and would thereby reduce their health care expenditure. Effective nursing practice will keep the health care organizations away from legal complications as well.
Participants and interdisciplinary Approach
The implementation of this intervention will include members from both inside the nursing profession and outside the nursing profession. In order to successfully conduct such interventions in a health care organization, the project will require a minimum of 2 nursing leader/ manager who would be supervising the educational program. The Nursing Leaders/ Managers will be responsible for monitoring the smooth functioning of the project, preparing study materials that would includes guidelines and policies to practice safe medication administration, conducting simulation training in which they would prepare critical scenarios for the nursing graduates, educate nursing graduates about new developments in the pharmacological area and teach them to calculate drug doses.
The participants list will also comprise of an interdisciplinary review team that will mostly include an experienced physician, pharmacists, and subject experts who will be supervising the nursing leaders and helping them to prepare the course work and simulation trainings for the nurses. They will be also involved in reviewing the reports of medication errors and perform root cause analysis and help the nurses in dealing with the situation. A member of the administration of the health care organization will also be included as a participant. The member will be responsible for lodging complaints of medication errors reported by the nurses and evaluating the types of errors and frequency of errors. He/ she will be also responsible for assessing the increase or decrease in the medication errors monthly and annually. All new nurse graduates and staff managers will be participating in this intervention and will be assessed on the level of improvement after the implementation of the intervention.
Each of these participants (member from the administration, physician, pharmacist, nurse manager/ leader and subject experts) are valuable as each of them will share their views, comments and expertise when solving critical issues and in educating new graduates. Root cause analysis of errors is an important step which will help the organization in minimizing the error rates. Additionally, the member from the administration department would not only help in tracking the incidence of the errors but will also help in preventing the nursing professionals from legal issues by identifying the potential threats before- hand. For the success of this intervention, inputs from each of these participants are valuable. Flynn (2012) reported that providing supportive environment (where physicians, leaders, organization leaders are supportive) for clinical practice and timely guidance and education imparted to the new graduates or staff nurses can effectively increase better communication with physicians, collegial relationships and job satisfaction, which in turn helped in reducing medication errors during practice. Flynn (2012) also showed that approximately 80% of the medication errors can be detected prior to the adverse events when interventions were properly implemented.
Conclusion
Medication errors are the growing concern for every health care organization. This is not only increasing the health care expenditure of the health care organizations but is also increasing the length of stay of the diverse patient population and thereby is increasing their personal health care expenditure as well. In many cases, these medication errors also result in sentinel events and legal issues, which is an additional burden for the health care organizations and the nursing professionals. This adds to mental stress, job dissatisfaction among nurses and thereby resulting in a nursing shortage. For decades, the nursing professionals were blamed for such errors, however, many researchers have pointed out that nurses are in the first line in the medication administration process; however, they cannot be solely blamed as there exist other causing factors which are generally ignored. These factors include transcription error, dispensing errors, prescription error, lack of communication, stress, etc. Therefore, there is an urgent need for the development of interventions that can reduce the prevalence of medication errors.
This capstone projects aim is to provide evidence, which indicates that implementing educational interventions to the new graduates and staff nurses can effectively reduce the incidence of medication errors. Furthermore, creating simulation training not only builds self- confidence in the nurses but also helps in instilling critical thinking and risk management skills in the nurses which further helps them in taking decisions on their own during critical situations. The education interventions were planned based on the thought process that imparting education and forcing the nursing professionals to use evidence base practice during their work process will increase competency among them. This would additionally, benefit the patient population as there will be little medication errors, and thus patient’s suffering will be less and so will their health care expenditure. It would also get better patient outcomes.
Furthermore, participation of non- nursing staffs, which includes physicians, pharmacists and members of the administration, helps in narrowing down the barriers between the physicians, nurses, and pharmacists. Active communication would further reduce complications and confusions and would thereby reduce prescription errors and drug dose errors. Physicians and pharmacists can further help the nurses understanding the ways to take care of critical events by taking the right step and by educating them about the right drugs and their doses, respectively. The participation of the members of the health care organization would help nurses in understanding the legal aspects better.
Therefore, implementation of these interventions during one’s clinical practice can effectively help one in reducing the prevalence of medication errors.
Reference
Bogner, M. (2009). Revisiting To Err Is Human a Decade Later. Biomedical Instrumentation & Technology, 476- 478.
CDC. (2012, January 15). Medication safety basics. Retrieved from Center for Disease Control and Prevention: http://www.cdc.gov/medicationsafety/basics.htmal#ref
Cheragi, M. M. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research, 228-231.
Dracup, K. B. (2003). Nursing Morbidity and Mortality Conferences. . American Journal of Critical Care, 491-494.
Flynn, L. L. (2012). Nurses’ practice environments, error interception practices, and inpatient medication errors. Journal of Nursing Scholarship, 180-186.
Frith, K. A. (2012). Nurse staffing is an important strategy to prevent medication errors in community hospitals. Nursing Economics, 288-294.
Groups at Major Risk. (2015). Retrieved from Andrea COok & Associates: http://www.alcooklaw.com/practice-areas/medication-error-injury/groups-at-most-risk/
ISMP. (2013). ISMP Quarter Watch Monitoring FDA Med Watch Reports. Retrieved from ISMP Quarter: www. ismp.org/Quarter Watch/
Katz, N. T. (2005). Safety climate in health care organizations:a multidimensional approach. . Academy of Management Journal, 1075-1089.
Mayo, A. M. (2004). Nurse Perceptions of Medication Errors What We Need to Know for Patient Safety. Journal of Nursing Care Quality, 209-217.
Privacy, security, and electronic health records. . (2014). Retrieved from Department of Health & Human Services: www.hhs.gov/ocr/privacy
Ramanujan, R. &. (2003). Latent errors and adverse organizational consequences: a conceptualization. Journal of Organizational BehavioR, 815-836.
Singleton, K. K. (2009). Understanding Cultural and Linguistic Barriers to Health Literacy. The Journal of Issues in Nursing.
