Improving Patient Quality and Safety
The practice problem involves medication errors. Medication errors are one of the primary healthcare problems in my practice causing adverse drug reactions to a patient in the healthcare setting. They occur when nurses fail to follow the five rights of medication administration(Martyn et al., 2019). The five rights of medication administration include right drug, right dose, right time, right route, and the right patient. A medication error is committed if a nurse administers the wrong drug, dosage, time, route, or to the wrong patient. Various statistics globally and in my clinical practice indicate the cases of medication errors. On average, the rate of medication errors is about eight to twenty-five percent (SingleCare, 2022). The rate of medication errors at home is estimated to be around two to thirty-three percent. Lack of proper dispensing commonly results in medication errors in my setting. Specifically, dispensing errors result to up to 55% of the total medication errors. In the United States, one in every five American citizens has experienced medication errors in the healthcare setting. Similarly, almost one in every five medication doses is given in an error in the healthcare settings. In my practice setting, older patients are likely to be affected by medication errors due to polypharmacy. Intravenous medications are responsible for the high rate of medication errors in my practice setting.
The quality improvement process utilized in the project is the PDSA. The plan-Do-Study-Act quality improvement process has four phases in problem-solving. It is commonly used in implementing change and improving a process (Ratner & Pignone, 2019). The four core elements include planning, doing, studying, and acting. The key aspect encompasses communicating the accomplishments and taking long-term steps to preserve and sustain them.
Importance of Quality improvement in reducing medication errors
Quality improvement in the healthcare setting is important. It has numerous benefits to the patients and the healthcare setting. Firstly, quality improvement reduces the cost associated with medication errors. According to the Common Wealth Fund (n.d), medication errors are expensive. The institute of medicine estimates the cost of medical errors at around 17 to 29 billion dollars every year in the United States (Tariq et al., 2020). Healthcare institutions can suffer various impacts of medication errors. The costs in the psychiatric institution range from compensations to those funding legal battles. Patients may require financial compensation for the harm caused in the event of a medication error.
The second importance of quality improvement is to reduce the adverse effects on patients. Medication errors have devastating effects on patients (Elliott et al., 2021). They may result in disability or even death. In the psychiatric hospital, medication errors resulted in the loss of life (Blouin et al., 2018). Quality improvement attempts to reduce the incidence of medication errors. Reduced number of medication errors translates to reduced cases of adverse effects and/or death to the patients. Thirdly, quality improvement improves patient satisfaction. Care that is safe and effective results in improved patient satisfaction. Quality allows the delivery of patient-cantered care (Mannion et al., 2018). The focus of the quality improvement models is the patients. This will allow the healthcare providers to administer value-based, respectful, and responsive care to patients. Finally, quality improvement ensures the delivery of effective and efficient care to the patients. By improving various processes, the organization can reduce the likelihood of medication errors (Shah et al., 2021). The healthcare system has become more data-driven. Improving the processes allows for the limitation of wasteful activities associated with medication errors. Streamlined and reliable processes are less expensive to maintain.
Quality Improvement Tools
The quality improvement tools that will support reducing and managing medication errors in the healthcare organization include a fishbone diagram, Pareto chart, run chart, and process flow chart. A fishbone diagram is a tool used for categorizing the potential causes of a problem. Healthcare practitioners can use the tool in healthcare settings to identify the root cause of a problem (CMS, n.d). The diagram combines a type of mind template and the practice of brainstorming. It is considered efficient as a test case technique, especially in determining the cause and effect of a particular phenomenon or problem in various settings. The diagram is a cause-effect diagram. The large bones signify the human factors in pharmacy, nursing, and equipment and supplies (CMS, n.d). The diagram can be utilized to inform nursing practice when preventing future errors. Healthcare practitioners can focus on human factors in nursing and pharmacy and the equipment and supplies. Human factors that may cause medication errors related to prescribing and dispensing in pharmacy include pharmacy technicians’ stress and burnout, pharmacy knowledge deficit, unavailability of pharmacists by phone, and lack of pharmacists on the nursing units. Human factors in nursing units include inadequate staffing, knowledge deficit, and workaround. In the equipment and supplies, the main causes of medication errors may be related to barcode labels, failing scanners, breaking down of unit does machines, and look-alike medications. When nurses and healthcare organizations address all these factors, medication errors will reduce significantly in the nursing unit.
Pareto Chart The chart is a bar graph. The length of the bars represents the cost and frequency of particular phenomena. The shortest bars are arranged with the shortest to the right and the longest bars on the left (ASQ, n.d). The tool can be used in multiple scenarios involving medical errors. Firstly, it can be used when analyzing statistics about the frequency of causes or problems in the process. Secondly, it can be used in the nursing unit when there are numerous problems or causes of medication errors and the unit wants to focus on the significant ones. Thirdly, it can be used in analyzing the broad causes of medication errors in the unit by analyzing its specific components. Finally, the chart can communicate the medication errors and their causes to other individuals and stakeholders. It can be a tool utilized in healthcare planning or as an indicator of healthcare quality. A run chart is represented in a line graph of medication errors plotted over time. Collection and plotting f the data over time can help healthcare practitioners to find patterns and trends in the processes (MDH, 2020). The healthcare providers can then utilize the trends and patterns to focus their attention on significant factors resulting in medication errors. The chart can determine the common causes of medication errors or special cause variation. The run chart can also be related to patient satisfaction. A process flow chart encompasses a chart or a diagram of steps in a process and their sequence. The flow chart can indicate the sequence in which medication errors occur in the healthcare setting. It can also be used to identify if the healthcare providers are implementing the policies to reduce medication errors in the nursing unit. It can be used to inform an intervention in the healthcare setting.
Application of PDSA
I will utilize the four steps of the PDSA quality improvement process. The four phases of the quality improvement process can determine potential solutions to medication errors. In planning, the healthcare organization can recruit a team to eliminate and prevent medication errors. Then a draft statement can be made focussing on what the organization is trying to accomplish. This includes a statement of changes that will eliminate or reduce medication errors in the facility. More information can be gathered regarding the best solution in planning. In planning, the aim is to minimize medication errors. The goal is to reduce medication errors by 70% within two months of implementation. The plan will be implemented in the nursing unit in the psychiatric facility. The intervention will involve educating the staff on the five rights of medication administration. The measures will include the number of medication errors two months after implementation.
In the second phase, the action plan is implemented. The implementation will involve educating the staff members on the five rights of medication errors. The measure will be the knowledge level and the medication errors statistics two months after implementation. Intervention success will depend on the number of medication errors.
In the third phase, a study identifies the plan’s success. Various data will be collected to identify the success of the intervention. In the nursing unit, the knowledge level of the nurses will be analyzed. The data indicating the incidence of medication errors will also be analyzed. Statistics indicated that educating the staff reduced the rate of medication errors.
Finally, in the act phase, the interventions are feasible; they can be incorporated into the policies and procedures in the organization. Since the goal has been met, the organization will set a rule involving periodic educating of staff members on the rights of medication administration. Various measures can be analyzed to determine the success of the interventions. The first raw measure is the incidence and the prevalence of medication errors. Upon implementation, the total number of errors is expected to diminish. Other measures include readmission rates, mortality rates, and legal and ethical cases involving medication errors. The measure of success is an outcome measure. The outcome is to reduce the rate of medication errors in the department.
American Society for Quality (ASQ) (n.d). What is a Pareto chart? https://asq.org/quality-resources/pareto#:~:text=A%20Pareto%20chart%20is%20a,which%20situations%20are%20more%20significant.
Blouin, D., & Tekian, A. (2018). Accreditation of medical education programs: moving from student outcomes to continuous quality improvement measures. Academic Medicine, 93(3), 377-383.
Centre for Medicare Services (CMS) (n.d). How to use the fishbone tool for root cause analysis. https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf
Commonwealth Fund (n.d). The financial implication of medical errors. https://www.commonwealthfund.org/publications/journal-article/2/apr/who-pays-medical-errors-analysis-adverse-event-costs-medical#:~:text=In%20addition%20to%20the%20harm,to%20%2429%20billion%20per%20year.
Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30(2), 96-105.
Mannion, R., & Davies, H. (2018). Understanding organizational culture for healthcare quality improvement. BMJ, 363.
Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviors beyond the five rights. Nurse education in practice, 37, 109-114.
Minnesota Department of Health (MDH) (2020). What is a run chart? https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/runchart.html
Ratner, S., & Pignone, M. (2019). Quality Improvement Principles and Practice. Primary Care: Clinics in Office Practice, 46(4), 505-514.
SingleCare (2022, January 20). Medication errors statistics 2022. https://www.singlecare.com/blog/news/medication-errors-statistics/#:~:text=Medication%20errors%20statistics%20by%20setting,Patient%20Safety%20Network%2C%202018).&text=Improper%20dispensing%20of%20medications%20results,BMJ%20Open%20Quality%2C%202018).
Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519065/
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