NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

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Capella University

NHS-FPX 4000 Developing a Health Care Perspective

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 Analyzing a Current Health Care Problem or Issue

Medication Errors (MEs) are a common healthcare concern worldwide. They lead to adverse patient outcomes, increased medical expenses and decreased trust in the healthcare organizations. Nurses involved in MEs undergo lasting emotional and legal consequences that hinder their ability to practice. This assessment reflects on a significant incident in the Intensive Care Unit (ICU) where a coworker unintentionally administered an incorrect medication. This paper seeks to deepen understanding of MEs, explore effective approaches and propose ethical strategies to address this concern.

Elements of Medication Errors

Drug-related errors are regarded as the most serious medical mistakes and are one of the leading causes of death among patients in the United States (U.S). Nurses and nursing students are normally involved in 39.69% of errors, as presented in the Iranian study (Tabatabaee et al., 2022). According to the World Health Organization, in the U.S, annually, 1.3 million people suffer adverse drug-related injuries because of MEs; the damage it causes costs about $42 billion (Naseralallah et al., 2023). Such errors cause severe side effects for patients and the health sector. Patients experience adverse drug reactions along with longer hospitalization and a high risk of death. Moreover, these also increase the cost of treatment due to increased periods of staying in the hospital (Tabatabaee et al., 2022).

They further deteriorate the relationship between the patients and health care professionals and mental and professional stress to the individuals involved (Bante et al., 2023). Poor communication channels often lead to misconceptions of inpatient treatment programs. Effective and standard procedures are essential to minimize these errors. MEs are exerting significant pressure on healthcare services and raising costs. Healthcare professionals and policymakers must focus on these factors to relieve the cost burden (Elhihi et al., 2023). MEs compromise patient safety, thus underlining the significant requirement for improving healthcare systems and procedures to prevent such an event.

The selected information is pertinent as it offers a detailed insight into the extent and consequences of MEs. Evidence from trusted sources and scholarly publications enhances the reliability of the discussion. It helps healthcare experts and policymakers comprehend the significance of tackling this issue through evidence-based solutions and promotes a safety culture within healthcare settings.

Analyze the Problem or Issue

MEs are preventable medication mistakes during prescribing, dispensing, and administering medications that predispose patients to unsafe clinical conditions (Naseralallah et al., 2023). MEs are estimated to cost the world economy about $42 billion annually (Tsegaye et al., 2020). The case in the scenario originated from a mistake where a colleague in the ICU administered the patient the wrong dose of medication, as captured on the Medication Administration Record (MAR). The factors for MEs are numerous and complex. They occur through a combination of human factors and systemic issues.

The contributing factors that increase the likelihood of MEs include communication breakdowns, workload distractions, and inexperienced staff. Human factors include interruptions and inattention, which elevate the risk of error (Tsegaye et al., 2020). Apart from this, failure to check medications before infusion, especially those with similar names or dosages, heightens the risk of MEs. Systemic factors also play an important role. Some systemic errors are associated with inadequate staff training and the absence of standardized procedures. In unclear or conflicting guidelines, the chances of MEs increase (Elhihi et al., 2023).

A research report reports that drug-related errors occur in 11.3% of cases due to frequent interruptions during medication administration (Isaacs et al., 2023). In most cases, these interruptions result from patient care or other pressing issues and increased workload. The study underlines other contributing factors, such as insufficient handoff communication, system inefficiencies and gaps in the skill of nursing professionals, as demonstrated in the scenario.

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

MEs pose substantial distress across various healthcare settings. It includes hospitals, outpatient clinics and long-term care facilities. These mistakes are mainly predominant in high-stress settings like the ICU, where the intricacy of patient conditions, the frequent administration of high-risk medications, and careful monitoring raise the probability of errors (Elhihi et al., 2023). The consequences of these drug-related events extend to multiple stakeholders. Patients are at the greatest risk. They potentially suffer harm or complications due to inappropriate medication administration.

According to Tariq and Scherbak (2024), healthcare experts such as physicians, pharmacists, nurses, and others involved in medication management all contribute to the risk of these mistakes. They are also impacted by the emotional and professional toll that results in anxiety, disciplinary measures, and a loss of patient confidence. Furthermore, the healthcare system bears the economic burden of increased treatment expenses and prolonged hospitalizations (Naseralallah et al., 2023). This highlights the urgent need for systematic education, well-established systems and a supportive healthcare setting to alleviate MEs.

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

Recent studies by Wondmieneh et al. (2020), provide data that offer insights into the influence of each factor and its overall effect. The study indicates that undertrained nurses are three times more likely to commit MEs than their well-trained counterparts. A lack of standardized protocols doubles the risk of medication mistakes. Additionally, excessive workloads, such as extended night shifts, can increase the probability of errors by fivefold.

This healthcare challenge is imperative for newly graduated nurses. It underscores their essential role in patient safety. Nurses are primarily responsible for administering medications, making them vital to preventing MEs by carefully reviewing medication administration records and adhering to standardized protocols (Bante et al., 2023). Addressing this issue early in their careers is critical for building confidence. It safeguards patient safety and cultivates a culture of responsibility and excellence in nursing practice.

Considering Options and Proposed Solution 

Several measures can contribute to reducing the risks of MEs in a healthcare organization. This involves organized staff education, advanced technology integration, strong teamwork, and effective communication. The purpose of this report is based on staff education or training and engaging BCMA systems to control patient risk profiles through MEs. For example, checklists during medication administration can curb confusion and ensure that accurate information about the patient is passed.

Healthcare institutions should ensure comprehensive training among all employees to improve medication safety. Simulation-based learning, seminars, and coaching can occur during induction. Periodic revision courses and training in drug administration can keep the nurses up to speed with the latest techniques and newer strategies (Rani, 2020). In addition, easily accessible digital learning modules and peer support networks heighten the importance of standardized administration practices since they raise nursing skills. The aim is to reduce MEs by devising effective nursing practices (Rani, 2020).

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

These training programs consume many resources and disrupt the nursing schedules by causing burnout. Technological intervention, such as BCMA systems, is one of the other significant interventions. It is an effective approach to limit the occurrence of MEs. Application programs are also utilized, including medication verification and alerts in real-time when an error occurs (Shermock et al., 2023). This technology helps avoid mistakes by cross-checking patients’ information and lab drug administration results. The application of BCMA requires careful planning. It entails introducing barcode scanners and compatible Electronic Health Record (EHR) software.

Staff should be competently trained to utilize and implement BCMA without any operational hitch. Misapplication of BCMA results in cascading disorganizations of workflows, increased workloads from failures of the systems and indirectly contributing to higher incidents of MEs. It is challenging for some health administrations to provide financial input towards setting up BCMA systems. Moreover, standardized handoff communication with structured formats like SBAR (Situation, Background, Assessment, Recommendation) will ensure that the most important medication information is communicated effectively during the shift or hand-off and in transition care. E-prescribing and Computerized Provider Order Entry (CPOE) ensure that errors are caused by inadequate handwriting or failure to read clearly and errors in dosage calculations (Shermock et al., 2023).

Outcomes of Not Addressing the Issue

Failure to address MEs within a healthcare organization can worsen the situation. It leads to increased patient morbidity and mortality and a loss of patient trust in the healthcare system. It also increases healthcare expenses due to longer hospital stays and extra treatments. Repeated mistakes can cause professional setbacks, legal penalties, and emotional distress for new graduate nurses. Wondmieneh et al. (2020), emphasize that ignoring MEs can weaken the safety culture in an organization. It leads to more adverse events and a decline in care quality.

Ethical Implications of the Proposed Solution

The ethical principles of autonomy (respect for patients’ rights), beneficence (to benefit), non-maleficence (to avoid harm), and justice (fair and equitable) are essential in clinical practice, particularly in strategies designed to reduce MEs (Varkey, 2021). Enhancing staff training aligns with the ethical principles of beneficence and non-maleficence. It aims to improve patient outcomes and minimize harm from MEs.

Healthcare professionals prioritize the well-being of patients by providing nurses with the expertise to administer medications safely (Shermock et al., 2023). Autonomy is honored by equipping nurses with the ability to make informed decisions in clinical settings. Justice is supported by safeguarding the right of all nurses, regardless of experience, to have equal access to inclusive training. It promotes a fair and secure environment for patients and healthcare providers. Similarly, implementing BCMA technology upholds the ethical principles of beneficence and non-maleficence by adding an extra layer of protection against MEs, thus boosting patient safety and equal care (Shermock et al., 2023; Varkey, 2021).

However, the principle of autonomy must be considered, as excessive reliance on technology diminishes nurses’ ability to make independent clinical decisions. The American Nurses Association (ANA) plays a pivotal role in ensuring high-quality care and setting ethical and professional standards for medication administration. The ANA Code of Ethics for Nurses stresses the importance of accountability, transparency, and advocacy for patient safety. Nurses are ethically bound to prioritize patient welfare, disclose errors openly, and follow legal and professional guidelines.

Conclusion

Preventing medication errors is essential for safeguarding patient safety and improving healthcare outcomes. A comprehensive approach, including enhanced communication, staff training, and integrating advanced technologies like BCMA, is crucial. By prioritizing these measures, healthcare organizations can significantly reduce errors, restore public trust, and ensure a safer environment for patients and healthcare professionals, ultimately fostering higher-quality care.

References

Bante, A., Mersha, A., Aschalew, Z., & Ayele, A. (2023). Medication errors and associated factors among pediatric inpatients in public hospitals of gamo zone, southern Ethiopia. Heliyon, 9(4), e15375. https://doi.org/10.1016/j.heliyon.2023.e15375

Elhihi, E. A., Hazazi, M. A., Adam, J. B., Romail, R. H. A., Tasneem, S. Z., Fallatah, D. M., Manzoor, F. K., Almoallad, F. T., Fallatah, M. M., Alfahmi, A. A., & Albandar, A. B. (2023). Unveiling the complexity of medication errors: A nursing perspective on contributing factors to medication errors. Evidence-Based Nursing Research, 5(4), 83–91. https://doi.org/10.47104/ebnrojs3.v5i4.316

Isaacs, A., Raymond, A., & Kent, B. (2023). Content analysis of nurses’ reflections on medication errors in a regional hospital. Contemporary Nurse, 59(3), 1–20. https://doi.org/10.1080/10376178.2023.2220432 

Naseralallah, L., Stewart, D., Price, M. J., & Vibhu Paudyal. (2023). Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: A systematic review. International Journal of Clinical Pharmacy, 45(6), 1359–1377. https://doi.org/10.1007/s11096-023-01626-5 

NHS FPX 4000 Assessment 4 Analyzing a Current Health Care Problem or Issue

Rani, S. (2020). To study the effectiveness of the training program on safe administration of drugs to reduce the medication error. Indian Journal of Holistic Nursing, 11(03), 12–19. https://doi.org/10.24321/2348.2133.202003 

Shermock, S. B., Shermock, K. M., & Schepel, L. L. (2023). Closed-loop medication management with an electronic health record system in U.S. and Finnish hospitals. International Journal of Environmental Research and Public Health, 20(17), 6680. https://doi.org/10.3390/ijerph20176680

Tabatabaee, S. S., Ghavami, V., Javan-Noughabi, J., & Kakemam, E. (2022). Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: A retrospective study of medical records. Bio Med Central Health Services Research, 22(1), 1420. https://doi.org/10.1186/s12913-022-08864-9 

Tariq, R. A., & Scherbak, Y. (2024, February 12). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 13, 1621–1632. https://doi.org/10.2147/ijgm.s289452  

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119 

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. BioMed Central (BMC) Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0