Capella 4020 Assessment 4

Capella 4020 Assessment 4 : Improvement Plan Tool Kit – Medication Administration Errors

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Capella University

Capella 4020 Assessment 4

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Improvement Plan Tool Kit – Medication Administration Errors

Quality and safety improvement is essential in healthcare facilities and for that purpose, a safety improvement tool kit is beneficial to improve the knowledge of healthcare providers in clinical practices. Almobarraz (2018) shared that knowledge sharing and interprofessional communication in an organization assist in finding collaborative solutions and build the capacity of every individual team (Almobarraz, 2018). This tool kit is established on medication administration errors (MAEs) which is a primary concern for nurses at Vila Health facility as described in assessment 2 of a safety improvement plan. It will help nurses and nurse leaders efficiently implement the improvement plan suggested in the last assessment as well as evaluate its success. The articles that are mentioned in this resource tool kit are taken from major databases like Google Scholar, Cochrane Library, Capella University’s Library, BioMed, and PubMed central.

Implementation and Sustainability of Safety Improvement Plan

To easily understand the purpose of the literature, this tool kit is categorized into three different categories:

MAEs and their global burden on healthcare systems.
Error reporting systems
Evidence-based best-practice solutions.

Overview and Incidences of MAEs

Asefa, K. kefelegn, Dagne, D., & Mekonnen, W. N. (2021). Medication administration error reporting and associated factors among nurses working in public hospitals, Ethiopia: A cross-sectional study. Nursing Research and Practice, 2021, 1–8. https://doi.org/10.1155/2021/1384168

This study was conducted in public hospitals in Ethiopia to analyze the extent of medication administration errors among nurses and the risk factors which are connected with the under-reporting of these errors. The study resulted in a 37.9% magnitude of the errors and some of the risk factors identified related to under-reporting were female gender, low confidence level, the belief of reporting is not important, more than 15 years of experience, and more than 10 patients dealt at a time.

This study is useful for nurses and nurse leaders who are responsible for implementing the safety improvement plan in their workplace. For example, by understanding the extent of MAEs in public hospitals of Ethiopia, stakeholders can identify the data of these errors in their particular hospital as well as examine if there is any under-reporting observed. Moreover, the risk factors described in the study are more likely to be found in the Vila Health facility as well. Hence, nurses and nurse leaders can apply this study in a useful way to implement a safety improvement plan and make it sustainable in their health facilities.

Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: A systematic review. Drug Safety, 43(6), 517–537. https://doi.org/10.1007/s40264-020-00918-3

This research is based on a systematic review of 54 studies which provides resources for causes of medication errors and the prevalence of these errors in hospitals as well as community settings. The usefulness of this resource can be understood by examining the risk factors of medication errors and the harmful events related to them. Nurses and their leaders need to identify the criticality of the problem in the Vila Health facility and undertake effective actions to prevent these risk factors that harm patients’ safety. This resource is valuable in decreasing patient harm and improving patients’ safety by carefully analyzing the harmful impacts of medication administration errors like an increased length of stay, worsened illness, and eventually deaths.

Alandajani, A., Khalid, B., Ng, Y. G., & Banakhar, M. (2022). Knowledge and Attitudes Regarding Medication Errors among Nurses: A Cross-Sectional Study in Major Jeddah Hospitals. Nursing Reports, 12(4), 1023-1039. https://doi.org/10.3390%2Fnursrep12040098

Capella 4020 Assessment 4

The purpose of this study was to analyze Saudi Arabian nurses to identify their knowledge regarding medication administration errors and explore their behaviors toward medication errors. This research article emphasizes the role of nurses to prevent medication errors that are harmful to patients. The study revealed a high prevalence of the MAEs and only 50% of the nurses were aware of these and showed a positive attitude toward the errors. This study is useful for nurse leaders and educators to educate their nursing workforce related to medication errors, risk factors, and preventive measures. It is essential to develop an insight before bringing any change in the practices. Nurses who are well equipped with the knowledge and have greater insight to change their perspectives are ready to bring greater reforms in their nursing practice hence improving patients’ safety.

Manias, E., Street, M., Lowe, G., Low, J. K., Gray, K., & Botti, M. (2021). Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. BMC Health Services Research, 21(1), 1-13. https://doi.org/10.1186%2Fs12913-021-07033-8

In this article, many personal, environmental, and communication factors have been discussed that cause medication administration errors within healthcare facilities. This article is useful for Vila Health facility nurses to identify the causative factors within their workplace, identify the need for improvement strategies and bring into implementation the safety improvement plan. This resource is valuable in terms of reducing patient harm through the active participation of nurses in identifying the loopholes in their practices and taking actions to improve the drawbacks eventually improving their care and enhancing patients’ safety.

Medication Error Reporting among Nurses

Rutledge, D. N., Retrosi, T., & Ostrowski, G. (2018). Barriers to medication error reporting among hospital nurses. Journal of Clinical Nursing, 27(9-10), 1941–1949. https://doi.org/10.1111/jocn.14335

The purpose of this study was to identify the hindrances that stop nurses from reporting medication administration errors. Moreover, analyzed the reliability of existing error reporting systems. The major barriers identified were extra time consumption and fear of consequences. A medication error reporting system is essential in every healthcare facility. This study is useful for Vila Health administrators to develop a reporting system within their facility and ensure its compliance among nurses. Furthermore, it is important to identify the obstacles which led nurses to under-report these errors and take immediate action against them.

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046

The authors initiated a methodological review of various articles to provide a summary of reporting medication errors and established effective reporting methods to recognize medication errors. The study concluded that the reporting system should be effective and safe for the reporter. For example in the case of the Vila Health facility, an effective reporting system can be established which maintains the confidentiality of the reporter and provides effective recommendations against the event. Moreover, managers should promote a culture of reporting to ensure patients’ safety is a priority.

Alshammari, F. M., Alanazi, E. J., Alanazi, A. M., Alturifi, A. K., & Alshammari, T. M. (2021). Medication error concept and reporting practices in Saudi Arabia: A multiregional study among healthcare professionals. Risk Management and Healthcare Policy, Volume 14, 2395–2406. https://doi.org/10.2147/rmhp.s281154

This article examined that 58.8% of healthcare workers do not report medication errors in hospitals based in Saudi Arabia. The study summarized the need for establishing reporting systems so that medication errors can be recognized and a safety improvement plan is implemented. Vila Health facility should do the same by generating an automatic or manual medication administration error reporting system which must be monitored by management so that effective and immediate actions are undertaken to prevent patients from ending up with severe complications.

Evidenced-based Best Practices

Ahsani-Estahbanati, E., Sergeevich Gordeev, V., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of Systematic Reviews. Frontiers in Medicine, 9. https://doi.org/10.3389/fmed.2022.875426

This article is based on a systematic review of various articles to elicit strategies that are useful to decrease medication errors. By the end of the research, eight different types of interventions were introduced. This study is useful for not only the frontline workers of the Vila Health facility but for policymakers as well. For example, policymakers need to focus on the implementation of the strategies and establish rigid policies against the errors such as zero tolerance policy for any medication negligence, so that significant improvement in patients’ safety is observed. Interdisciplinary collaboration and teamwork are essential for the implementation of a safety improvement plan thus this resource is valuable for administrators and other stakeholders as well to improve the overall safety of the patients and enhance quality health care.

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235

This Irani study was piloted to identify the interventions which can be taken to prevent medication administration errors in the hospital. Some of the strategies identified are reading the order carefully, training and education, awareness about lawsuits, safety measures for high-risk medications, and upskilling nurses to perform medications through accreditation. This study concluded that nurses must act professionally so that appropriate practices are observed. Nurse leaders at Vila Health facilities can utilize this resource to initiate some of the strategies in their hospital for example continuous training for nurses, safety policies, and adherence to the safety guidelines.

Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to the implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J, 10, 45-46. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2019/03/Commentary-14.pdf

Capella 4020 Assessment 4

This study recommends the utilization of a computerized medication order entry system and bar-coded medication administration system. These systems are important to avoid medication errors as well as reduce the costs associated with these errors. Initiation of these systems in the Vila Health facility will help nurses follow standardized steps to administer medication so that medication safety is ensured and error events are reduced.

Ciapponi, A., Fernandez Nievas, S. E., Seijo, M., Rodríguez, M. B., Vietto, V., García-Perdomo, H. A., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Garcia-Elorrio, E. (2021). Reducing medication errors for adults in hospital settings. The Cochrane Database of Systematic Reviews, 11(11), CD009985. https://doi.org/10.1002/14651858.CD009985.pub2

This article recommends interventions like medication reconciliation, computerized physician order entry/ clinical decision support systems (CDSS), barcode medication administration, and reduced working hours and analyzes the effectiveness of these strategies. This resource is helpful for Vila Health facility’s stakeholders to identify the best practices from the literature and implement them in their hospitals to reduce medication administration errors and prevent patients’ safety.

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 204209862096830. https://doi.org/10.1177/2042098620968309

The focus of this study is to advise some interventions along with enabling policymakers to promote the culture of interprofessional collaboration among nurses, physicians, and pharmacists to maintain medication safety. Stakeholders of Vila Health facility should also encourage their nurses to collaborate with physicians and pharmacists so that medications safety is maintained from prescription to the administration phase.

Conclusion

This resource tool kit is valuable to improve nurses’ and nurse leaders’ knowledge related to medication administration and enables them to effectively implement and maintain the sustainability of safety improvement plans. To ensure medication safety, and recognition of the problem, interprofessional collaboration to devise interventions, implement them, and further evaluate the outcomes is essential to improve the quality of care and enhance patients’ safety.

References

Almobarraz, A. (2018). Knowledge sharing in healthcare centers: Practices and influences. SRELS Journal of Information Management, 229–236. https://doi.org/10.17821/srels/2018/v55i5/130336

Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J, 10, 45-46. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2019/03/Commentary-14.pdf

Capella 4020 Assessment 4

Overview and Incidences of MAEs

Capella 4020 Assessment 4

Capella 4020 Assessment 4

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