The evolving complexity of the healthcare system and the increasing incidences of patient harm in healthcare led to the emergence of patient safety as a discipline. Patient safety is a fundamental concept in the delivery of healthcare services. Even though healthcare organizations strive to maintain patient safety, the complexity of the healthcare system makes absolute patient safety a challenging goal to achieve. The World Health Organization (WHO) defines patient safety as the reduction of healthcare-associated patient errors and adverse events Lawati et al. (2018). Additionally, WHO estimates that in high-income countries, for every ten patients receiving care, one is harmed, and a wide range of factors are associated with such adverse events (World Health Organization, 2019). Most of these events are, however, avoidable. In this paper, an analysis of medication errors as a patient safety issue identified in the Vila Health scenario will be analyzed while incorporating guidelines and strategies that can be used to mitigate the risks.
Factors Leading to Medication Errors
Medication errors in healthcare are preventable at different levels. In healthcare, medication errors are a global issue. Some of the factors leading to medication errors are attributed to primary-secondary care interface issues, computerized information systems, work environments, tasks, medicine, patients and healthcare professionals. According to WHO, the limited existence of communication between primary and secondary care contributes to medication errors and the fact that there is insufficient justification for secondary care (Alemu et al., 2017). The evolution of technology in healthcare has led to the implementation of computerized healthcare systems, which present healthcare professionals with difficulties while generating drug prescriptions. For instance, system glitches may lead to missed alerts and default dose regimens. Computerized information systems in healthcare may also contain inaccurate patient records, thereby leading to incorrect repeat prescriptions. Essentially, most of these systems are developed in such a way that the design allows for human error. More importantly, repetitive systems for medication ordering and authorization may reduce attentiveness to tasks.
Delegate your assignment to our experts and they will do the rest.
The healthcare environment is a complex work environment characterized by workload and time pressures, which further contribute to medication errors (Wondmieneh et al., 2020). Additionally, limiting physical environments characterized by inadequate lighting and ventilation affects healthcare professionals' ability to function effectively. Most organizations have insufficient resources, which cripples the care continuum, especially due to disruptions, interruptions, and the lack of standardized procedures. Medication errors may also arise during the process of naming, labeling and packaging of medicines. Patients with comorbidities and those practicing polypharmacy have a high risk of medication errors, which may be precipitated by patient characteristics, including illiteracy and language barriers (Alemu et al., 2017). Healthcare professionals with inadequate knowledge and experience and those who lack therapeutic training often make more medication errors. Communication between healthcare professionals and patients is vital in care delivery, and in most cases, fragmented communication leads to errors.
Evidence-Based and Best-Practice Solutions for Medication Errors
Various studies have been explored to establish ways through which medication errors can be reduced. Notably, the reduction of medication errors and the improvement of patient safety needs a systems approach. Some of the solutions identified by the WHO, which can improve medication prescription practices, include the implementation of education programs, the use of clinical pharmacists and computer technology. Medication review conducted by a clinician or a pharmacist not only improves prescription practices but also reduces hospital readmissions. Medication review and reconciliation incorporate a system that allows the rectification of discrepancies at discharge, a common problem in outpatient care settings (Kreckman et al., 2018). Computerized provider order entry (CPOE) is a system implemented in various health care facilities, which decreases the recurrence rate of medication errors in in-patient care settings. Education programs aimed at improving healthcare practitioners’ prescription practices have also been shown to improve prescription and dispensing practices. According to a wide range of research studies, the implementation of multifaceted interventions for medication error reduction is the most feasible strategy to improve medication prescription practices (Gorgich et al., 2015). Enhancing accountability systems that will enhance error-reporting leads to system improvement hence reduced incidences of medication errors (Zhou et al., 2018).
Role of Nurses in Care Coordination to Improve Patient Safety and Reduce Costs
The Institute of Medicine’s 2010 report ‘ The Future of Nursing: Leading Change, Advancing Health ’ identifies the critical role of a nurse in healthcare which involves meeting the demands for affordable, quality. Safe, accessible, and patient-centered healthcare services (Salmond & Echevarria, 2017). Nurses participate in various actions that are directly related to reducing medication errors and improving patient safety while reducing costs. For instance, nurses are responsible for developing care plans guided by patient needs and preferences, which contributes to improved care delivery. Nurses make care transition smooth through patient and family education at discharge, thereby facilitating continuity of care across care settings.
Stakeholders whom Nurses Coordinate with to Enhance Safety
Enhancing patient safety by reducing medication errors depends on nurses' ability to coordinate with various stakeholders involved in the care delivery process. Coordination with patients ensures that the nurse understands patient needs and preferences. Care coordination ensures a smooth care transition, such that the transitional factors associated with medication errors are reduced. Nurses also coordinate with other healthcare professionals, including doctors, social workers, care managers and support staff, thereby addressing the potential gaps in meeting the medical needs of the patient while considering the patient’s financial needs and health preferences. While doctors address the medical needs of the patients, social workers address the social needs.
Conclusion
Health professionals strive to save numerous lives; nevertheless, the prevalence of associated error is high. Medication errors are a worldwide threat for healthcare personnel and patients’ safety; hence, all healthcare professionals should decrease human and system errors. Training, teamwork, and education through structured initiatives are the most appropriate strategies for improving patient safety. Being tolerant of team members' contributions, reducing barriers in reporting errors, and promoting a collaborative work environment has the most substantial outcome o patient safety improvement and medication error reduction.
References
Alemu, W., Belachew, T., & Yimam, I. (2017). Medication administration errors and contributing factors: A cross-sectional study in two public hospitals in Southern Ethiopia. International Journal of Africa Nursing Sciences , 7 , 68-74. https://doi.org/10.1016/j.ijans.2017.09.001
Gorgich, E. A., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2015). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science , 8 (8), 220. https://doi.org/10.5539/gjhs.v8n8p220
Kreckman, J., Wasey, W., Wise, S., Stevens, T., Millburg, L., & Jaeger, C. (2018). Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team. BMJ Open Quality , 7 (2), e000281. https://doi.org/10.1136/bmjoq-2017-000281
Lawati, M. H., Dennis, S., Short, S. D., & Abdulhadi, N. N. (2018). Patient safety and safety culture in primary health care: A systematic review. BMC Family Practice , 19 (1). https://doi.org/10.1186/s12875-018-0793-7
Salmond, S. W., & Echevarria, E. (2017). Healthcare transformation and changing roles for nursing. Orthopaedic Nursing , 36 (1), 26-27. https://doi.org/10.1097/nor.0000000000000320
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. BMC Nursing , 19 (1). https://doi.org/10.1186/s12912-020-0397-0
World Health Organization. (2019, September 13). Patient safety . WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/patient-safety
Zhou, S., Kang, H., Yao, B., & Gong, Y. (2018). An automated pipeline for analyzing medication event reports in clinical settings. BMC Medical Informatics and Decision Making , 18 (S5). https://doi.org/10.1186/s12911-018-0687-6
