Assessment 4: Improvement Plan Tool Kit

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2 School of Nursing and Health Sciences, Capella University NURS-FPX4020: Improving Quality of Care and Patient Safety Dr. Brandi Ballantyne June 10, 2022

Introduction

Reducing medication errors has been discussed in various settings and by various persons. However, it still remains an issue of concern to the safety of patients as well as the quality of care offered. Therefore, in this paper, I will devise an improvement plan tool to help healthcare professionals especially nurses to minimize medication errors. The paper contains annotated bibliography of twelve articles, in four topics, each having three articles.

Importance of communication

Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E.,. & Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International journal of clinical practice, 69(11), 1257-1267.

This research compares written communication to face to face communication. Vermeir, et al., (2015) argue that face to face I important in obtaining full details, but written communication remain the best method of communication, especially when ordering medications or prescriptions. This article teaches nurses to always opt for written orders, to avoid medication errors. In case of an order made through the phone, the nurse is encouraged to note it down immediately, to prevent errors

1 Center for Drug Evaluation and Research. (2019, August 23). Working to Reduce Medication Errors. https://www.fda.gov/drugs/drug-information-consumers/working-reducemedication-errors.

The article delivers comprehensive information regarding medication errors. This includes causes, adverse effects, and also ways of minimizing medication errors. Additionally, it offers important information of how nurses should practice good communication with patients, involving them in their own care. This article may be useful to nurses in including their patients in their own care, like reporting any side effects, or any reactions caused by drugs. Nurses can also utilize the document to educate patients on importance of communicating any problems in regard to their health.

Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al Kindi, S. N. (2015). Patient safety culture among nurses. International nursing review, 62(1), 102-110.

The results of this research indicate that nurses operating at certain Omani hospitals had a higher positive perception of the client safety mindset in the areas of coordination across departments, institutional training and progressive development, as well as feedback and communications concerning mistake. The client is often cared for by a diverse team of medical professionals and in a number of medical environments inside the hospital. Because of this, communication and collaboration within hospital units are needed in order to deliver treatment that is both effective and safe for the patient. This article helps healthcare professionals to develop proper communication across department.

Proper documentation

Edwards, M., & Moczygemba, J. (2004). Reducing medical errors through better documentation. The health care manager, 23(4), 329-333.

This study seeks to investigate the reduction of medication or errors through a better documentation process. According to the article, failure to document anything means that it is not done. This can possibly lead to overdosing. Nurses are required to write down any medication they have administered, to prevent double administration or the medication which may risk the patient health, as well as lower the quality of care. This publication may help nurses to understand that failure to document medications administered as well as time could have a detrimental effect to the patient, and that they are required to keep comprehensive records of everything they do to prevent medication errors

1 Martin, A., & Holland, J. (2019). 1 35 Assessing the completeness of medication reconciliation documentation by resident physicians at hospital admission for pediatric asthma patients. 3 Paediatrics & Child Health, 24, e14-e15.

The publication investigates the impacts of failure to maintain medication reconciliation on patients. According to the authors, failure to document the medications previously taken at home during admission may post a challenge on discharge prescription, and cause medication errors. Therefore, by understanding the underlying risks, nurses need to utilize this knowledge to capture all the details during admission, as well as take part in reviewing discharge prescription for their patients, since they are patient’s advocates.

3 Wang, L., Blackley, S. V., Blumenthal, K. G., Yerneni, S., Goss, F. R., Lo, Y. C.,. & Zhou, L. (2020). 3 A dynamic reaction picklist for improving allergy reaction documentation in the electronic health record. Journal of the American Medical Informatics Association, 27(6), 917-923.

In this article, the authors discuss about the importance of not only disclosing medication errors, but also recording them properly and clearly. The author argues that there are increased chances of committing an additional medication error when the initial one is not recorded. In regard to nurses, they need to develop the culture of documenting errors, irrespective of the repercussions that might occur, in order to protect the patient from more errors, as well as to ensure patient safety and quality of care.

Individual Measures to Reduce MedicationErrors

deClifford, J. 4 M., Caplygin, F. M., Lam, S. S., & Leung, B. K. (2007). 5 Impact of an emergency department pharmacist on prescribing errors in an Australian hospital. 4 Journal of Pharmacy Practice and Research, 37(4), 284-286.

The authors examine the prescription errors that are connected to the emergency department pharmacist. It has ben noted out that timely retrieval of a patient’s medication history and health records could be essential in reducing prescription errors. Although this article directly addresses pharmacist, it is useful to nurses, since it teaches them to have complete medical and health records of a patients, before administering any medications, this is extremely useful in preventing medication errors in hospitalized patients, and during discharge.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). 6 Medical error reduction and prevention. StatPearls [Internet].

This article describes different ways that can be used to prevent medication errors. It does comment about double -checking. The authors stated that double-checking patients’ information right before a surgical procedure is important, to prevent surgical errors. Similarly, double checking medications before administration is crucial in reducing medication errors. Inviting the patient to confirm the procedures that are about to be done on then is a way of double checking, to prevent errors. This article invites nurses to double check procedures and medications, to verify them and ultimately reduce medication errors.

Jones, J. 1 H., & Treiber, L. A. (2018, July). 7 Nurses’ rights of medication administration: In Nursing forum (Vol. 53, No. 3, pp. 299-303).

Although the five rights of medication administration have been made mandatory in efforts to reduce medications errors, the authors state that these rights are still not followed. The article calls upon all nurse to ensure that they perform their role as caregivers, in providing quality and safe care to their patient through observing the rights of medication administration. This article is important to nurses since it urges them to take a personal and individual responsibility to ensure that patient receive the right medication, and dosages via the right route.

Significant methods of disclosing medication errors

1 Abdel-Latif, M. M. (2016). 1 Knowledge of healthcare professionals about medication errors in hospitals. 3 Journal of basic and clinical pharmacy, 7(3), 87.

According to the findings in this article, the awareness of medication errors among healthcare professionals varies. Also, it was identified that those with poor knowledge on medication errors are at high risk of performing medication errors, since they do not know the precautions that help to minimize them. This publication educates nurses to be education seekers, to ensure that they are up-to-date with any recent evidence-based procedures that help to reduce medication errors.

Robertson, J. J., & Long, B. (2018). Suffering in silence: The Journal of emergency medicine, 54(4), 402-409.

Many of the medication errors go unreported due to the fear or imperfection, according to the author. This study aims to give understanding and encouragement for those who are trying to recover after being engaged in an unpleasant medical incident but feel as if they are battling the healing process alone. This paper encourages nurses and other health care providers to report any6 medication errors to ease the guilty that be associated with the error committed.

3 Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S.,. & Hake, M. E. (2016). 1 How to perform a root cause analysis for workup and future prevention of medical errors: a review. 3 Patient safety in surgery, 10(1), 1-5.

In this article, the authors discuss the application of route cause analysis to expose medication errors. Medical practitioners are encouraged to ensure that they gather as much information from patients as possible, in order to understand the causative factors, as well as device an appropriate management plan to prevent medication errors. This information is important to nurses especially in gathering sensitive information, as well as reporting variables that are crucial to patients’ safety.

References

1 Abdel-Latif, M. M. (2016). 1 Knowledge of healthcare professionals about medication errors in hospitals. 3 Journal of basic and clinical pharmacy, 7(3), 87.

1 Center for Drug Evaluation and Research. (2019, August 23). Working to Reduce Medication Errors. https://www.fda.gov/drugs/drug-information-consumers/working-reducemedication-errors.

Edwards, M., & Moczygemba, J. (2004). Reducing medical errors through better documentation. The health care manager, 23(4), 329-333.

Jones, J. 1 H., & Treiber, L. A. (2018, July). 7 Nurses’ rights of medication administration: 1 Including authority with accountability and responsibility. 7 In Nursing forum (Vol. 53, No. 3, pp. 299-303).

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S.,. & Hake, M. E. (2016). 1 How to perform a root cause analysis for workup and future prevention of medical errors: a review. 3 Patient safety in surgery, 10(1), 1-5.

Robertson, J. J., & Long, B. (2018). Suffering in silence: 8 medical error and its impact on health care providers. The Journal of emergency medicine, 54(4), 402-409.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). 6 Medical error reduction and prevention. StatPearls [Internet].

NURS-FPX4020_007780_1_1223_OEE_33 - NURS-FPX4020 - SPRING 2022 - SECTION 33

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