Policy Proposal (Ass 2) (1*)

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Running head: POLICY PROPOSAL 1

Policy Proposal

Learner’s Name

Capella University

Health Care Law and Policy

Policy Proposal

May, 2019

POLICY PROPOSAL 2

Policy Proposal

Despite being recognized as one of the region’s top choices for health care, Mercy

Medical Center has areas for opportunity. Medication errors in the medical and surgery unit have

seen a 50% increase from 4 in 2015 to 8 in 2016. Nute suggests that medication errors may result

in longer hospital stays and higher rates of mortality and morbidity (as cited in Kavanagh, 2017).

According to Rafter, Hickey, Conroy, Condell, O’Connor, Vaughan, Walsh, and Williams, these

errors may result in an increase in the cost of health care (as cited in Kavanagh, 2017). Incidents

resulting from medication errors require additional resources and more care interventions, which

leads to a decrease in the efficiency of health care services provided. Considering the expense

medication errors can entail for patients and health care practitioners, there is a need for an

organizational policy to address the shortfall in the reduction of medication errors.

Strategies to Resolve Medication Errors

Medication Error Analysis

According to Zhan, Smith, Keyes, Hicks, Cousins, and Clancy, because of the fear of

repercussions such as disciplinary action being taken, a large number of medication errors go

unreported (as cited in Weant, Bailey, & Baker, 2014). However, learning from these errors will

help reduce their recurrence and improve care interventions. Every reported error is an

opportunity for the development of a countermeasure and will help avoid or reduce the impact of

the same error in the future (Weant et al., 2014).

A health care system that exposes patients to medical errors needs to be critically

evaluated. Failure mode and effects analysis is a technique that can be used to analyze incidents

related to medication errors. Under this method of analysis, the medical center can commission

the formation of a multidisciplinary committee that will review processes susceptible to errors.

Commented [A1]: Good introduction that meets the goal of “explaining the need for the organizational policy.”

POLICY PROPOSAL 3

Based on the inadequacies observed, the committee can classify the medication errors according

to the priority in which they need to be addressed (Weant et al., 2014). As part of the analysis,

the committee will review the steps in the process, the things that could go wrong, the reasons

behind them, and the possible repercussions (Institute for Healthcare Improvement, n.d.). Based

on these factors, the committee can recommend actions to reduce the possible errors in the

process. The analysis will end with an evaluation of the prescribed actions for improvement

(Centers for Medicare and Medicaid Services, n.d.).

Automated Dispensing Cabinets

An automated dispensing cabinet is a computerized medication distribution system that is

installed in patient care units. It stores, dispenses, and electronically tracks drugs at the point of

care. Using these cabinets can help the medical center profile patients, reduce the time taken to

retrieve medication, and track inventory on a real-time basis (Weant at al., 2014). These cabinets

usually contain high-alert and controlled medications and can only be accessed using an ID and a

password. With the use of these cabinets, nurses will not have to walk long distances to collect

the required medication (Rochais, Atkinson, Guilbeault, & Bussières, 2014).

The implementation of both these strategies can be affected by certain environmental

factors. The efficacy of medication error analysis can be affected if error incidents are

underreported or if errors are incorrectly documented. Barach and Small state that error incidents

are usually reported verbally despite how frequently they occur. This can lead to an

underreporting of errors (as cited in Elden & Ismail, 2016). Moreover, verbally communicating

errors can lead to errors in documenting data. According to Claudia, Sharon, DeVSP, Merrell,

and Gail, the scope for the improvement of patient safety will be limited if errors are discussed

verbally (as cited in Elden & Ismail, 2016). With regard to the use of automated dispensing

POLICY PROPOSAL 4

cabinets, incorrect restocking is one of the problems that can arise, which can result in treatment

delays. Apart from this, inaccurate documentation of doses retrieved from the automated cabinets

can also affect timely treatment. This can lead to incorrect administration of medication

(Hamilton-Griffin, 2016). Additionally, when care providers such as nurses are affected by

heavy workloads and are preoccupied with various tasks at once, they are likely to get

interrupted or distracted while collecting and administering medication from the cabinets. To

ensure that these issues do not arise, the pharmacy can be asked to share an updated list of the

stock on a daily basis. A staff member or nurse can be tasked to cross-check the cabinet stock

against the list provided by the pharmacy. Further, reassessing the stock from time to time and

using barcode technology for restocking medications can also reduce the possibility of such

errors occurring (Pennsylvania Patient Safety Authority, n.d.).

Clinicians need to be provided with continuous education on new drugs, procedures, and

policies so that the proposed strategies are effectively implemented. Apart from that, creating

simulation environments will also instill confidence in care providers about their competency in

medication administration. It is necessary to create a culture of safety within the organization,

which will allow care providers to freely report errors without the fear of negative consequences

and coercion.

Policy for Managing Medication Errors

Policy Statement

Medication errors pose a risk to patient safety and public health. This policy is a guide for

health care practitioners to enable them to take appropriate action in the event of a medication

error. The guidelines and recommendations will provide a framework to improve the practice of

the two proposed evidence-based strategies.

POLICY PROPOSAL 5

Scope

The policy applies to nursing staff, medical staff, emergency and allied care practitioners,

and staff employed at the pharmacy. All concerned individuals are responsible for the

prescription, dispensation, and administration of medicines.

Guidelines for Implementing Evidence-Based Strategies

The multidisciplinary local patient safety committee (which includes professionals from

various disciplines such as nursing, pharmacy, and medicine) should regularly go over the

existing action plan to improve health care outcomes. The committee must assess apprehensions

and go over events that possibly endanger patient safety. It should also analyze trends in

medication errors as well as address systemic weaknesses (Polnariev, 2016). According to

Schlesselman, around half of all possible medication error events can be averted by patient

education. Pharmacists can counsel patients when they are visited for consultations. Training

sessions on counseling patients will aid the effectiveness of pharmacists’ consultations. These

training sessions should include an emphasis on asking open-ended questions to patients (as cited

in Polnariev, 2016) such as the following three prime questions: (1.) What did the physician tell

you the medication is for?, (2.) How did the physician tell you to take the medication?, and (3.)

What did the physician tell you to expect? The sessions should also emphasize listening to

patients patiently, learning to identify inaccuracies in their responses, and demonstrating to them

the use of medication devices (Lauster & Srivastava, 2013).

Before the administration of any medication, a review of medication orders by a

pharmacist will ensure the safety of the hospital’s medication system. Barcode verification

should be put in place for the stocking of medications. Limited amounts of medication should be

placed in the cabinets, and the cabinets should be refilled frequently (Hyland, Koczmara,

Commented [A2]: I think the idea of the multidisciplinary team is good; the active involvement of all key stakeholders will be critical to success.

POLICY PROPOSAL 6

Salsman, Musing, & Greenall, 2007). For the nursing staff, barcode verification will validate the

7 rights of medication administration: right patient, right drug, right dose, right time, right route,

right reason, and right documentation. These 7 rights will be verified while administering

medication. A nurse will scan the barcode on his or her identification badge, on the patient’s

wristband, and on the medication. Software will analyze the real-time data, and based on the

database, it will generate approvals or warnings (Shah, Lo, Babich, Tsao, & Bansback, 2016).

When choosing and placing medications within automated dispensing cabinets, products

that look alike should not be placed inside the same multiple-product drawer. Medications should

be retrieved from the cabinet for one patient at a time and administered without delay. Training

sessions about the right practices related to the use of automated dispensing cabinets should be

organized for the staff. The staff must be educated about unsafe practices that can affect patient

outcomes negatively such as retrieving medications in advance and retrieving medications for

multiple patients. They must also be educated about the need to report problems such as similar

drug name pairs being displayed on the drug selection screens on the cabinets (Hyland et al.,

2007).

Stakeholder Involvement in Implementing Proposed Strategies

Assistance can be sought from key administrative personnel such as the chief executive

officer, director of nursing, or chief operating officer. These individuals can form a quality

committee where they can share their expertise and monitor the effective implementation of the

proposed strategies. By establishing role accountability and articulating the organization’s

quality improvement norms from time to time, the key administrative personnel can reinforce a

culture of safety among the health care staff (Parand, Dopson, Renz, & Vincent, 2014). The main

nursing staff should also be involved because they deal with a lot of medication administration

POLICY PROPOSAL 7

problems firsthand. They can help in the identification of the inadequacies that cause medication

errors (Blake, 2017). While receiving prescriptions at the pharmacy, pharmacists can check for

discrepancies and contact the prescribers for any changes in orders before the prescriptions are

filled out (The Health Foundation, 2012).

The involvement of the hospital administration and the care providers will lead to

transparency in the implementation of the strategies. It will bring in multidisciplinary expertise,

create room for debate and discussion, and ensure that the parties involved have a say in

decisions concerning these strategies. Therefore, a partnership between the hospital

administration and the care providers will ensure that the proposed strategies are implemented

effectively.

Conclusion

Incidents resulting from medication errors can reduce a health care organization’s

efficiency. However, the implementation of medication error analysis and the use of automated

dispensing cabinets can substantially reduce the chances of such errors occurring. Above all, the

most important thing for the proposed policy to be effective is the creation of a culture of safety

and quality improvement at Mercy Medical Center.

POLICY PROPOSAL 8

References

Blake, R. W. (2017). Reducing medication errors through workflow redesign. Journal of Nursing

& Interprofessional Leadership in Quality & Safety, 1(2), 5. Retrieved from

https://digitalcommons.library.tmc.edu/cgi/viewcontent.cgi?referer=https://www.google.c

om/&httpsredir=1&article=1006&context=uthoustonjqualsafe

Centers for Medicare and Medicaid Services. (n.d.). Guidance for performing failure mode and

effects analysis with performance improvement projects. Retrieved from

https://cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/downloads/GuidanceForFMEA.pdf

Elden, N. M. K., & Ismail, A. (2016). The importance of medication errors reporting in

improving the quality of clinical care services. Global Journal of Health Science, 8(8),

243–251. Retrieved from https://ncbi.nlm.nih.gov/pmc/articles/PMC5016354/

Hamilton-Griffin, K. (2016). Developing improvement strategies on the use of automated

dispensing cabinets to reduce medication errors in a hospital setting (Doctoral

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com.library.capella.edu/docview/1810160234?pq-origsite=summon

Hyland, S., Koczmara, C., Salsman, B., Musing, E. L. S., & Greenall, J. (2007). Optimizing the

use of automated dispensing cabinets. The Canadian Journal of Hospital Pharmacy,

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canada.org/download/cjhp/cjhp0711.pdf

Institute for Healthcare Improvement. (n.d.). Failure modes and effects analysis. Retrieved from

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ents/MOCPAP/FailureModesandEffectsAnalysis_IHI.pdf

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Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety.

British Journal of Nursing, 26(3), 159–165. Retrieved from

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JGwJMF6C2qUI-aNlKX_qSSpSvY&hl=en&sa=X&ved=2ahUKEwibhI6s0-

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and patient safety: A systematic review. BMJ Open, 4(9). Retrieved from

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Pennsylvania Patient Safety Authority. (n.d.). Problems associated with automated dispensing

cabinets. Retrieved from

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Polnariev, A. (2016). Using the medication error prioritization system to improve patient safety.

Pharmacy and Therapeutics, 41(1), 54–59. Retrieved from

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Rochais, É., Atkinson, S., Guilbeault, M., & Bussières, J.-F. (2014). Nursing perception of the

impact of automated dispensing cabinets on patient safety and ergonomics in a teaching

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Shah, K., Lo, C., Babich, M., Tsao, N. W., & Bansback, N. J. (2016). Bar code medication

administration technology: A systematic review of impact on patient safety when used

with computerized prescriber order entry and automated dispensing devices. The

Canadian Journal of Hospital Pharmacy, 69(5), 394–402. Retrieved from

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The Health Foundation. (2012). Evidence scan: Reducing prescribing errors. Retrieved from

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Weant, K. A., Bailey, A. M., & Baker, S. N. (2014). Strategies for reducing medication errors in

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