A root-cause analysis involves identifying the causes of adverse occurrences and near misses to develop mitigative measures. The causes of problems within a healthcare setting are identified and responded to through a systematic root-cause analysis approach. The method identifies preventive measures to mitigate and prevent similar problems in the future. This paper researches medication errors in geriatric patients. This study was conducted at the Bristol Park Nursing facility. The paper discusses medication errors and how evidence-based strategies are used to develop safety improvement plans.
Root-Cause Analysis of Medication Errors in Geriatric Inpatients
Costly consequences such as patient harm or death, additional medical intervention, and patient's length of stay may be realized from medication errors. Elderly patients may experience adverse drug reactions, hospitalization, morbidity, or even mortality. A recent study conducted by Pierson indicated that more than 8% of the cases resulted in adverse medical conditions of the patients, with one extreme case resulting in hospitalization (Pierson et al., 2017; Sukkarieh-Haraty & Hoffart , 2017). The research was based on 631 cases of medication errors.
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Another root-cause analysis study conducted on 40 cases of medication errors examined its harmful effects. The research was done by quality improvement experts, ancillary staff, a supervisor, and a physician (Hande et al., 2017). More than 50% of the cases resulted from distractions during medical preparation or administration, and 88.9% of the clinical errors made during medication preparation and administration resulted in negative consequences. The standard errors included wrong dosages, wrong medications, and patient mismatch. The most practical consequences on patients included headache, changing blood sugar and pressure, vomiting, nausea, headache, and changing consciousness levels.
Evidence-Based Strategies to Reduce Medication Errors
The most commonly used strategies and optimization systems to mitigate medication include medical reconciliation, proper staff training, and health information technologies such as barcode scanning, automated dispensing cabinets, computerized order entry systems, and electronic health records ( Ambuta s et al., 2017 ). Studies published in the recent decade have intensified their support for an Information Technology multifaceted system used to prevent medical errors and improve patient safety.
Medical reconciliation in a medical facility is essential in the oversight of transfer and discharge hence avoiding most medical errors during admissions. Failure for reconciliation and miscommunication increases the risk of adverse events (Alotaibi & Federico, 2017). Alotabi and Federico (2017) suggest that "More than 40% of medication errors result from adequate medication reconciliation at care transitions."
Proper staff training is essential to the mitigation of medical errors and safe medication management. It is therefore vital to retrain staff frequently in order to improve safety for patients. The following steps could be used to improve the safety and quality of medication administration; retaining more experienced nurses, creating guidelines of medication administration, and staff training.
The prevention of drug monitoring errors can reduce medication errors. Computer-controlled telephone systems can be used for monitoring geriatric patients (Alotaibi & Federico, 2017). Research shows that medication adherence improves by more than 17% for the patients monitored by telephone.
Improvement Plan
The proposed improvements must be set in place to reduce medication errors and improve patient safety. Some of the proposed improvements are proper staff training and education on medication safety management and electronic health information technology systems. Some of the Information Technology-based systems that effectively aid in preventing medication errors include the Automated Medication Dispensing Machine, Electronic Barcode-Assisted Medication Administration, and the Computerized Physician Order Entry Systems. A study done by Federico and Alotaibi (2017) concluded that "Health information technology presents numerous opportunities for improving and transforming healthcare which includes; reducing human errors, improving clinical outcomes, facilitating care coordination, improving practice efficiencies, and tracking data over time".
The Electronic Barcode-Assisted Medication Administration eliminates the possibility of human error. An example is giving the wrong medications to a patient, and the system declines to process the administration and sends an error message ( The Joint Commission , N.d ). A barcode scan is a more efficient method than hand data entry. Alotaibi and Federico (2017) illustrated that using the Electronic Barcode-Assisted Medication Administration data entry system decreases the chances of medication errors by 57%. The author's research further proved that the implementation of Electronic Medication Administration record and the Barcode Assisted Medication Administration reduces the overall rate of Adverse Drug Events and hence improves patient safety.
Medication distribution and dispensing control can be tracked by the Automated Medication Dispensing Machines introduced in the late 1990s. The system helps identify medication preparation errors. The systems provide patient care medication units along with electronic tracking. The electronic tracking feature of the systems helps in the identification and correction of potential diversion. The nurses are saved much time from end-of-shift manual tracking. A step towards more excellent patient safety is realized by carefully planning the medical cabinets and utilizing them to their full potential.
Computerized Physician Order entry affects healthcare delivery in complex ways. General factors that confound or facilitate the rollout of the system have to be considered. Various order changes by users are fed into the Computerized Physician Order Entry Systems and are reviewed by the system. Any entry of unsafe drug combinations is detected, and an error message is displayed to the user. The system takes into consideration patients' health issues such as allergies and drug-to-drug interactions. More developments are being made on the computerized physician order entry systems. The adoption of these systems will have impacts on the improvement of patient safety and quality incentives.
All staff should be trained on the handling of the technology systems. The overall goal is achieved through the implementation of effective medication safety management. Personal digital assistants provide medical information needed for counseling, dispensing, and prescribing to pharmacists and other prescribers. Research shows that Personal Digital Assistants reduce transcribing errors by up to 22% ( Institute for Healthcare Improvement , N.d ).
Conclusion
The unintentional and preventable medication errors can result in severe injury or deaths in geriatric patients. This root-cause analysis identifies lack of communication, transferring or discharge failure of reviewing medication reconciliation during admission, and interruption and distraction during drug medication preparation as the critical causes of medication errors within healthcare settings. Medication errors are reduced by using evidence-based strategies such as implementing adequate information technology-based systems and performing medication reconciliation. Staff training and health technology-based system installation are some of the effective ways of reducing medication errors. The author's research further proved that the implementation of Electronic Medication Administration record and the Barcode Assisted Medication Administration reduces the overall rate of Adverse Drug Events and hence improves patient safety. Globally, 59% of the general population use prescription medication, and the number increases to more than 85% of patients aged more than 65 years. The studies referenced by the author for this research were limited but applied the evidence available to the general population.
Both system and human mistakes can result in medication errors. These mistakes are preventable and, therefore, need not to happen. Researches done adds to the knowledge within this field, and strategies to minimize medication errors have been implemented. The need for more developed systems and further research is evident based on the growing requirement for more standardized procedures.
References
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety . Saudi medical journal, 38(12), 1173–1180. https://doi.org/10.15537/smj.2017.12.20631
Pierson, S., Hansen, R., Greene, S., Williams, C., Akers, R., Jonsson, M., & Carey, T. (2018). Preventing medication errors in long-term care: results and evaluation of a large-scale web-based error reporting system. Quality & safety in health care , 16(4), 297–302. https://doi.org/10.1136/qshc.2007.022483
Hande, K., Williams, C. T., Robbins, H. M., & Christenbery, T. (2017). Leveling evidence-based practice across the nursing curriculum. The Journal for Nurse Practitioners, 13(1), e17–e22.
Sukkarieh-Haraty, O., & Hoffart, N. (2017). Integrating evidence-based practice into a Lebanese nursing baccalaureate program: Challenges and successes. International Journal of Nursing Education Scholarship , 14 (1), 441–442.
Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). Readiness, barriers and potential strength of nursing in implementing evidence-based practice. International Journal of Caring Sciences , 13 (2), 1203–1211.
Institute for Healthcare Improvement. (n.d.). Josie King - What happened to Josie? [Video] . Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx
The Joint Commission. (n.d.). Sentinel event policy and procedures . https://jointcommission.org/sentinel_event_policy_and_procedures
Institute for Healthcare Improvement. (n.d.). Introduction to trigger tools for identifying adverse events . Retrieved from http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx
Ambutas, S., Lamb, K. V., & Quigley, P. (2017). Fall reduction and injury prevention toolkit: Implementation on two medical-surgical units . Medsurg Nursing , 26 (3), 175–179, 197.
