NURS FPX4010 Assessment 4: Stakeholder Presentation

NURS FPX4010 Assessment 4: Stakeholder Presentation

Plan Proposal For Medication Errors

Peeches Headlam

CAPELLA UNIVERSITY

SCHOOL OF NURSING AND HEALTH SCIENCES

Mar 2021

Content

NURS FPX4010 Assessment 4: Stakeholder Presentation

  • Organizational and patient issue of medication errors
  • Evidence-based interdisciplinary plan
  • Implementing interdisciplinary plan
  • Managing human and financial resources
  • Evidence-based criteria to evaluate success of plan
  • Evidence-based criteria to evaluate the outcomes

NURS FPX4010 Assessment 4: Stakeholder Presentation

Medication errors

  • Near misses and adverse effects may harm the patients
  • Medication errors are one of the major reasons for adverse effects
  • The errors affect organizational functions and processes 
  • Medication errors increase work burden
  • Medication errors lead to blame culture and conflicts
  • It is difficult to identify errors at times

Types of medication errors

  • Ordering or prescription errors
  • Transcribing errors
  • Documenting errors
  • Dispensing errors
  • Administering errors
  • Dosage errors

NURS FPX4010 Assessment 4: Stakeholder Presentation

Effects of medication errors

  • Delayed care
  • High cost of care
  • Mortality and morbidity
  • Long-term side effects
  • Sense of guilt, disappointment, fear and inadequacy
  • Lower patient trust 

PDSA Cycle

  • Plan
    • Identify and create a team
    • Create aim and objectives
    • Analyze current approach
    • Identify potential interdisciplinary solution

NURS FPX4010 Assessment 4: Stakeholder Presentation

Evidence-based interdisciplinary plan

  • Do phase
    • Role-based interdisciplinary team
    • Error reporting system with physician order entry
    • Direct communication channel in reporting system
    • Checklist to compare prescription, EHR, dosage, and medicine
    • Bar-code-based medication system
    • Shared decision-making with root-cause analysis

Evidence-based interdisciplinary plan

  • Report any changes in packaging or brand
  • Do not use abbreviations
  • Limit interferences during drug administration through
    • Tabards
    • Nurse collaboration 
  • Communication protocols for faster response

Study and Act Phase

  • Examine the results to check
    • Analyze error rates
    • Calculate response rate
    • Compare cost with benefit
    • Analyze burnout and perspectives
    • Analyze patient satisfaction
    • Observed side-effects
    • Identify need for change

Managing Financial & human resources

  • Motivate the health care professionals to increase performance
  • Increase nurse to patient ratio
  • Manage burden and schedule the work
  • Solve conflicts
  • Provide support, incentives, and resources
  • Procure error reporting, bar-code, and checklist system
  • Manage finances without compromising with quality of care

NURS FPX4010 Assessment 4: Stakeholder Presentation

Criteria to evaluate success

  • Reduced medication errors
  • Increase in response rate
  • Reduction in cost
  • Reduction in burnout
  • Increase in patient satisfaction

Criteria

  • Faster root-cause analyze
  • Increase in effective communication
  • Higher job satisfaction
  • Increased trust in patients
  • Increased computer science competencies and skills 

NURS FPX4010 Assessment 4: Stakeholder Presentation

Conclusion 

Medication errors include prescription, dispensing, dosage calculation, and drug administration errors. As stakeholders’ units are involved, an integrated system with EHR, medication reporting and communication, bar-code, tabards to reduce interferences, a checklist for verification, and education and training staff are beneficial in reducing errors and promote quality culture. 

References

  • Bosma, B., Hunfeld, N., Roobol-Meuwese, E., Dijkstra, T., Coenradie, S., & Blenke, A. et al. (2020). Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands. International Journal Of Clinical Pharmacy43(1), 66-76. https://doi.org/10.1007/s11096-020-01101-5
  • Desai, M., Patel, N., Shah, S., Patel, P., & Gandhi, A. (2016). A study of medication errors in a tertiary care hospital. Perspectives In Clinical Research7(4), 168. https://doi.org/10.4103/2229-3485.192039
  • Kang, H., Park, H., Oh, J., & Lee, E. (2017). Perception of reporting medication errors including near-misses among Korean hospital pharmacists. Medicine96(39), e7795. https://doi.org/10.1097/md.0000000000007795
  • Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administration safety by reducing distractions and interruptions. Journal Of Nursing Care Quality35(4), E58-E62. https://doi.org/10.1097/ncq.0000000000000473
  • Musharyanti, L., Claramita, M., Haryanti, F., & Dwiprahasto, I. (2019). Why do nursing students make medication errors? A qualitative study in Indonesia. Journal Of Taibah University Medical Sciences14(3), 282-288. https://doi.org/10.1016/j.jtumed.2019.04.002
  • Palese, A., Ferro, M., Pascolo, M., Dante, A., & Vecchiato, S. (2019). “I am administering medication—please do not interrupt me”: red tabards preventing interruptions as perceived by surgical patients. Journal Of Patient Safety15(1), 30-36. https://doi.org/10.1097/pts.0000000000000209
  • Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal Of Africa Nursing Sciences13, 100235. https://doi.org/10.1016/j.ijans.2020.100235
  • Schmidt, K., Taylor, A., & Pearson, A. (2017). Reduction of Medication Errors: A Unique Approach. Journal Of Nursing Care Quality32(2), 150-156. https://doi.org/10.1097/ncq.0000000000000217
  • Stewart, D., MacLure, K., Pallivalapila, A., Dijkstra, A., Wilbur, K., & Wilby, K. et al. (2020). Views and experiences of decision‐makers on organisational safety culture and medication errors. International Journal Of Clinical Practice74(9). https://doi.org/10.1111/ijcp.13560
  • Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001
  • Trakulsunti, Y., Antony, J., Dempsey, M., & Brennan, A. (2020). Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study. International Journal Of Quality & Reliability Management38(1), 339-362. https://doi.org/10.1108/ijqrm-10-2019-0334

NURS FPX4010 Assessment 4: Stakeholder Presentation

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