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Capella 4020 Assessment 1

Capella 4020 Assessment 1 Enhancing Quality and Safety

Student Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Enhancing Quality and Safety – Scenario

Mrs. Smith, a 68-year-old retired schoolteacher, was admitted to the cardiology ward of City Hospital due to increasing episodes of shortness of breath and fatigue. These symptoms worried her family, mainly because of her long-standing hypertension and a recent diagnosis of heart failure. Her primary care physician had referred her to the hospital for more intensive management of her condition. Upon evaluation by the cardiologist, it was decided to initiate her on metoprolol, a beta-blocker known for its efficacy in managing hypertension and improving life expectancy in heart failure patients.

A prescription was duly entered into the hospital’s Electronic Health Record (EHR) system. The cardiologist verbally relayed the medication change to the head nurse, emphasizing the need for a prompt initiation. However, during medication dispensation, the on-duty nurse misread the prescription in the EHR, juggling multiple patients and tasks. Mistaking ‘metoprolol’ for ‘metformin,’ the nurse prepared the dose for Mrs. Smith. When administering, Mrs. Smith, the meticulous teacher, queried why she was being given medication for diabetes. The nurse reassured her, attributing the medicines to her complex medical regimen.

It was not until the following morning, during the routine medication rounds, that the error was flagged. Another nurse recognized the mistake, leading to an immediate rectification and an apology to Mrs. Smith. While no harm came to Mrs. Smith due to the quick intervention, the incident showed a systemic flaw that needed urgent attention.

Factors Leading to Medication Administration Safety Risk

In the situation of Mrs. Smith, the medication error is evident. It is a stark example of the gaps present in the current healthcare system. The case highlights several challenges. Each challenge can be dissected further into specific contributing factors.

  • Similar Drug Names: One of the most common reasons for medication errors is the phonetic and orthographic similarities between drug names. According to the U.S. Food and Drug Administration (FDA), many medication errors have resulted from drug name confusion, and they have documented over 1,400 distinct pairs of drug names involved in mistakes due to their similarities (FDA, 2021). In our case, the confusion between ‘metoprolol’ and ‘metformin’ can be seen as a part of this more significant issue.
  • Verbal Communication: Relying verbally with an accompanying written or electronic verification can be safe. The Institute for Safe Medication Practices (ISMP) has listed verbal orders among its “Top Ten Medication Errors and Hazards” (ISMP, 2019). Misheard or misinterpreted words, especially in noisy hospital environments, can lead to errors like the one Mrs. Smith experienced.

Capella 4020 Assessment 1

  • Lack of Double Checks: The absence of a systematic double-check mechanism for medication dispensation is a clear gap in patient safety protocols. The Joint Commission has consistently emphasized the need for independent double-checks to prevent high-risk medication errors (The Joint Commission, 2019). Mrs. Smith’s error could have been caught before the administration without a secondary verification.
  • EHR Shortcomings: While electronic health records have revolutionized healthcare documentation and communication, they could be more foolproof. The error of not flagging a diabetic medication for a non-diabetic patient highlights a potential area for improvement in the EHR’s safety alert system. According to a study, EHRs have reduced medication errors; they can also introduce new errors, underscoring the need for ongoing system optimization (Upadhyay & Hu, 2022). By examining these factors, healthcare systems can develop more comprehensive strategies to counter medication errors and enhance patient safety.

Evidence-Based and Best Practice Solutions

Medication errors, such as Mrs. Smith’s experience, highlight critical challenges in healthcare. It is vital to address these errors to enhance patient safety. Evidence-based and best-practice solutions offer a roadmap for improvement. Such strategies can be seamlessly integrated into the existing healthcare system.

  1. Drug Name Clarification: Implementing a system to flag drugs with phonetically or orthographically similar names can dramatically decrease medication errors. The World Health Organization (World Health Organization, 2019) highlights that such a system could significantly reduce medication errors at both the prescribing and dispensing stages. By reducing these errors, healthcare systems can save costs by avoiding unnecessary treatments, hospital readmissions, and potential legal litigations associated with misadministration.
  2. Electronic Alerts: Fully leveraging the capabilities of Electronic Health Records (EHRs) is pivotal. EHRs, when optimized, can identify and alert healthcare professionals about medications incongruent with a patient’s diagnosed conditions. The Agency for Healthcare Research and Quality (AHRQ, 2019) underscores the importance of meticulous medication management using EHRs. Besides improving patient safety, a robust EHR system can save costs by reducing time-consuming manual checks and the costs associated with correcting medication errors post-administration.
  3. Enhanced Training: Ongoing, targeted training sessions on medication safety are crucial. A study emphasized the value of continuous training, especially for medications with a higher risk of being confused (Elkeshawi et al., 2022). Training healthcare professionals regularly ensures adherence to best practices and proves cost-effective in the long run by preventing errors, reducing potential malpractice claims, and enhancing overall patient care quality.

Nurses’ Role in Coordinating Care for Enhanced Medication Safety

Nurses are crucial in the healthcare system, often serving as the primary defense against medical errors. Their coordination and vigilance can significantly enhance patient safety during medication administration, all while optimizing operational costs. Firstly, the fundamental medication verification step nurses can take is verifying medication details before administration. In Mrs. Smith’s case, this would involve cross-referencing the medication’s name, dose, and intended purpose against the patient’s medical records and present conditions. If Mrs. Smith had been questioned about her medications and understood what each was for, she might have immediately recognized the inconsistency when metformin was introduced (De Baetselier et al., 2021).

Secondly, open and collaborative communication is essential to establish and maintain open communication channels with the patient and the prescribing physician. Whenever there is a doubt or inconsistency observed – such as a cardiac patient being given a diabetes medication – nurses should feel empowered to seek clarification. Active communication can act as a safety net, catching potential errors before they translate into adverse events. Thirdly, in interdisciplinary collaboration, Nurses can extend their coordination beyond the immediate medical team.

Collaborating closely with pharmacists can act as another layer of verification, ensuring that any prescribed medication aligns with a patient’s current health status and other ongoing treatments. If a similar partnership had been active in Mrs. Smith’s scenario, the pharmacist could have flagged the metformin prescription, thus averting the error (De Baetselier et al., 2021).

Essential Stakeholders in Enhancing Medication Safety

Nurses are crucial in the healthcare system, often serving as the primary defense against medical errors. Their coordination and vigilance can significantly enhance patient safety during medication administration, resulting in avoided costs associated with complications, extended hospital stays, and potential legal actions. Firstly, the fundamental medication verification step nurses can take is verifying medication details before administration. In Mrs. Smith’s case, this would involve cross-referencing the medication’s name, dose, and intended purpose against the patient’s medical records and present conditions.

Avoiding such mistakes can also prevent the extra financial burden on the hospital, given the potential need for additional treatments due to adverse medication reactions. If Mrs. Smith had been questioned about her medications and understood what each was for, she might have immediately recognized the inconsistency when metformin was introduced (De Baetselier et al., 2021). Secondly, open and collaborative communication is essential to establish and maintain open communication channels with the patient and the prescribing physician. This ensures patient safety and reduces costs by preventing the downstream effects of medication errors. Whenever a doubt or inconsistency is observed, such as a cardiac patient being given diabetes medication, nurses should feel empowered to seek clarification.

Active communication can act as a safety net, catching potential errors before they translate into adverse events. Thirdly, in interdisciplinary collaboration, Nurses can extend their coordination beyond the immediate medical team. Collaborating closely with pharmacists can act as another layer of verification, ensuring that any prescribed medication aligns with a patient’s current health status and other ongoing treatments. If a similar partnership had been active in Mrs. Smith’s scenario, the pharmacist could have flagged the metformin prescription, thus averting the error (De Baetselier et al., 2021).

Conclusion

The case of Mrs. Smith exemplifies the significant challenges posed by medication errors within healthcare. These incidents not only shed light on existing loopholes but also emphasize the shared duty among healthcare practitioners to champion patient safety. By fostering interprofessional collaboration, refining training methodologies, and harnessing technological advancements, a safer healthcare horizon can be envisioned. All involved parties, from the frontline nurses to the backend IT experts, must collaboratively strive for a healthcare environment where safety is paramount.

References

Agency for Healthcare Research and Quality. (2019). Electronic health records | PSNet. Ahrq.gov. https://psnet.ahrq.gov/primer/electronic-health-records 

De Baetselier, E., Dilles, T., Feyen, H., Haegdorens, F., Mortelmans, L., & Van Rompaey, B. (2021). Nurses’ responsibilities and tasks in pharmaceutical care: A scoping review. Nursing Open, 9(6). https://doi.org/10.1002/nop2.984 

Elkeshawi, R., Maddox, K., Xenophontos, A., & Hampson, K. (2022). Safety considerations for the inpatient medication-use process in pediatric and neonatal patients. Patient Safety, 30–35. https://doi.org/10.33940/pediatrics/2022.1.3 

Capella 4020 Assessment 1

ISMP. (2019). Institute for Safe Medication Practices. https://www.ismp.org/ 

Lei, K. C., Loi, C. I., Cen, Z., Li, J., Liang, Z., Hu, H., Chan, T. F., & Ung, C. O. L. (2023). Adopting an electronic medication administration system in long-term care facilities: A key stakeholder interview study in Macao. Informatics for Health and Social Care, 1–15. https://doi.org/10.1080/17538157.2023.2165084 

U.S. Food and Drug Administration. (2021). U S Food and Drug Administration Home Page. Fda.gov. https://www.fda.gov/ 

Upadhyay, S., & Hu, H. (2022). A qualitative analysis of the impact of electronic health records (EHR) on healthcare quality and safety: Clinicians’ lived experiences. Health Services Insights, 15, 1–7. https://doi.org/10.1177/11786329211070722 

World Health Organization. (2019). Medication Without Harm. https://www.who.int/initiatives/medication-without-harm 

Capella 4020 Assessment 1