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NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

In the United States, the death rate attributable to various medication mistakes ranges from 7,000 to 9,000. Thousands of patients may have suffered due to medication mistakes that have negative repercussions (Tariq et al., 2020). Every year, medication mistakes result in a $40 billion increase in healthcare expenses for every 7 million patients (Tariq et al., 2020). In order to improve patient happiness, quality of treatment, nursing competences, collaboration between healthcare system and pharmacies, and creation of a top medical facility, the issue must be addressed. In order to suggest and give an action plan to implement the solution, this article will investigate pharmaceutical error issues and strategies to reduce them while taking its efficacy and ethical ramifications into account (Tariq et al., 2020).

The assessment starts by outlining the various causes and contributing elements to the problem, the consequences of these causes and the problem, the various types of medication errors, the various solutions implemented by health systems, a proper review of the solutions, the suggested solution, its ethical implications, and an evidence-based effective implementation approach to put the solution into practice and assess it. NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

Elements of the Medication Errors problem/issue

Medication errors can be deadly or innocuous, but they always lower the standard of treatment and exacerbate tensions between doctors, pharmacists, medical transcriptionists, and other stakeholders. Additionally, it erodes patients’ confidence in the medical system (Dirik et al., 2018). 

Packaging mistakes, prescription mistakes, dispensing mistakes, medication administration, miscommunication, and negative drug responses are the problem’s components. There are two different kinds of packaging mistakes (Faraj Al-Ahmadi et al., 2020). The first one has to do with inaccurate information and bad printing. Inaccuracies in dose, similar names, and chemical makeup are examples of incorrect information. The only way to remedy this problem is for the nurses to notice side effects and report them so that the drug may be investigated if it has the accurate info but the incorrect product, or vice versa. Additionally, if there are any tiny flaws in the package, the dispensing machine can recognize it. Due to packing mistakes, medications may be substantially different, posing risks to patients and increasing health difficulties. The likelihood of mistakes is average (Faraj Al-Ahmadi et al., 2020).

NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

The second kind of medication error involves frequent and unexpected changes to the medicine’s initial package, naming sequence, and color. The occurrence of drug mishaps followed a change in labeling (Faraj Al-Ahmadi et al., 2020). Due to a breakdown in information on the change in packaging between pharmacists and nurses, it causes uncertainty among nurses. The likelihood of mistakes is average. From 6% to 77.7% of prescriptions were filled incorrectly (Shrestha & Prajapati, 2019). Due to identical pharmaceutical and medicine names, inaccurate and insufficient patient and drug information on prescriptions, and automated physician order input, these errors are extremely probable and are connected to lapses, blunders, and calculations errors (CPOE). Disparities between the medication handed out and prescriptions are connected to dispensing mistakes and prescription errors (Shrestha & Prajapati, 2019).

NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

The most common causes of drug administration mistakes include incorrect timing, incorrect dose and omission, incorrect administration rate, incorrect preparation, and providing medications due to a dispensing error without first checking and getting in touch with the pharmacist distribution unit. The mistake rate ranges from 8% to 25%, and nurses are mostly responsible for the errors (Chua et al., 2017). Individual mistakes and interferences with the administration process can both lead to drug administration problems. Because of the rise in patient volume and turnover rate, these mistakes are more likely to happen. Ineffective communication makes it more likely that a medication error will occur because preventative and remedial measures cannot be taken (Chua et al., 2017). This widens the distance between the prescriptions, dispense, and drug administration departments, which breeds conflict and a culture of blame. Harmful effects of drugs. Lack of acknowledgement, inadequate suggestions, inaccurate information, and delayed responses are all examples of poor communications (Chua et al., 2017).

Analysis of the Medication Errors Problem 

Medication errors are described as any avoidable incidents that might endanger patients or have other negative impacts. Negative medication responses, which might be unanticipated, undesirable, and harmful, are referred to as adverse effects (Zarea et al., 2018). An injury caused by an incorrect dose, administration, or other mistakes is referred to as an adverse medication event. Injury may result in illness or even death.

As a nurse, it is my responsibility to reduce pharmaceutical mistakes since they compromise patient security. Furthermore, as medical treatment is required to address the negative occurrence, such mistakes raise hospital expenses. It, therefore, raises readmission and hospital stay rates. As the caregiver ratio declines, such mistakes add to the strain on nurses. Errors may result in legal action and/or disciplinary punishment. As a result, the patient has less faith in healthcare, which suggests that the hospital provides low-quality care (Zarea et al., 2018). 

Effect on Patients, Nurses and Other Health Care Professionals

Medication misjudgments may have a negative effect on the patients. Negative effects extend beyond physical health issues to psychological ones as well, as patients who contract additional illnesses or infections while in the hospital are more likely to experience stress, anxiety, and depression (Zarea et al., 2018). For instance, following bad medication events, patients start to feel lack of motivation to seek therapy for symptoms that are comparable. This suggests that drug mistakes result in undesirable side effects, and undesirable side effects result in psychological problems.

NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

The financial burden on patients is further increased by unfavorable consequences since they require longer hospital stays and more expensive treatment to reverse them. Some negative impacts result in morbidity or death while others cause medical issues that last a lifetime (Dillon et al., 2018). For instance, a pharmacy technician who had no institutional education or experience caused a woman who had been admitted to a Midwestern state to pass away by making several typing errors. The mistakes included spelling mistakes, and inaccurate patient records (Dillon et al., 2018).

Since more medication errors signify unprofessional behavior, the overall negative consequence of the medication problem is poor work satisfaction. As numerous departments including the pharmacy, dispensing units, nursing staff, doctors, and other healthcare personnel are engaged in medication errors issues, blame cultures are rather widespread in the medical field (Dionisi et al., 2021). Conflicts cause anxiety and sadness in nurses because they work in an unsupportive setting. Conflict will arise, for instance, if a patient dies from a high dosage. Due to many units, determining the fundamental reason requires time. Because nurses are at the bottom of the food chain, they will often bear the brunt of the blame, which can cause dread, poor mental health, and decreased work fulfillment (Dionisi et al., 2021).

Potential Solutions for Medication Errors

The first step in the approach is to create a direct channel of interaction among nurses, doctors, pharmacists, and vendors in order to lower the likelihood of medication error, dose calculations going wrong, distribution mistakes, and delayed medication administration. This may be accomplished by including medication administration errors and verifying data with paperwork and EHR. To ensure that everything is validated before moving on to the next phase, the second method is to supply checklists technology for every unit (Hughes & Blegen, 2018). The name, dose, manufacturer, and clinical records for all medications must be verified by pharmacists. To eliminate typing and transcribing mistakes, it can be accomplished by introducing a bar-code-based medicine system (Hughes & Blegen, 2018). The third option is to inform everyone on the proper usage of acronyms. To eliminate medical mistakes, it is preferable to avoid using the abbreviation. These solutions’ drawbacks include the need for a new system, finances, and a potential for excessive reliance on technology (Hughes & Blegen, 2018).

NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue

The following remedy is to put in place a procedure for communicating with error-reporting technology so that comments on specific medications and patients may be provided for a speedy resolution (Tariq et al., 2020). Additionally, fewer dose mistakes are made when a med tech with distinct portions for medications and audio labels to identify the contents of the syringe is used. Preventing misunderstanding and delays in medicine administration can be achieved by informing nurses and doctors about changes to packaging. By employing tabards with various indicators, the issue of external interference during delivery can be lessened (Tariq et al., 2020). As a consequence, there are fewer interferences and fewer mistakes. In order to confirm that the correct medication is given to the patient, nurses must also check the EHR and patient evaluations. Training and educating the stakeholders to promote multidisciplinary partnerships is another crucial component. The secrecy of personal data and unintended mistakes that cause treatment (Tariq et al., 2020).

The ramifications of not putting the solutions into practice and neglecting the problem include steadily increasing risks to patients, supplementary health issues, higher health care costs, more readmission rates, detrimental psychological impact on both patients and staff, moral, expert, and legal repercussions, more conflict, and relatively low patient and healthcare effectiveness.  The ideal option is to combine all of the methods mentioned into a single system because different remedies apply to various faults. Medication administration errors are prevented by using tabards, electronic healthcare records and assessment tools for confirmation, interconnected reporting and interaction applications to watch over medication, delivering, and interaction, devices, labels, and voice tags for dosage computation,  and training health care providers to communicate with one another to avoid errors and identify their underlying causes (Nguyen et al., 2017).

Ethical Principles

Four moral norms and the right of self-determination, benevolence and respect for human dignity, transparency and the right to information, and veracity can be used to group ethical concerns relating to medication errors (Varkey, 2021). The concepts of independence and the right to self-assurance acknowledge patients’ rights to make decisions and take action based on their own viewpoints and perceived advantages. Medical care providers have a moral obligation to inform patients of their ongoing agreement for treatment, even in the case that a medical error has occurred. (Varkey, 2021).

Medical service providers are required by law to act in the patients’ best interests and without malice in order to uphold the standards of effectiveness and nonmaleficence. As a reason, medical care providers may face ethical dilemmas while balancing the patient’s potential risk with the patient’s prolonged advantages (Vaismoradi et al., 2021). Even while mistakes might range in severity, they always have negative effects on the patient, the person who made the mistake, and the system as a whole. Medical care providers should take all necessary precautions to prevent further harm from being done as a result of an error (Vaismoradi et al., 2021).

Medical care providers have a moral obligation to unearth the information patients require for well-informed, independent decision-making. The patient’s rights declaration demands the full account of a medical error (Vaismoradi et al., 2021). The rule of veracity mandates that medical professionals provide comprehensive, accurate, and impartial information in a way that makes it easy for patients to understand. Having open communication regarding medical errors promotes trust. (Vaismoradi et al., 2021). Providing accurate information about medical mistakes promotes trust. For instance, a drug administration error may be rapidly resolved, bad effects are reduced, workplace disputes are eliminated, patient wellbeing is promoted, and underlying problems are discovered when truth-telling is preferred over a fear-based culture and blaming. Every approach from the preceding part has been included into the system (Vaismoradi et al., 2021).

NURS FPX 4000 Assessment 4: Analyzing a Current Health Care Issue


Medication error reduction is consistently prioritized in nursing. The five medication rights provide education with a good foundation for preventing error, but we need continue educating, and reduce interruption. The best course of action for medication error is to continue discussing them and apply evidence-based practice to reduce future errors. Giving our patients the safest, most effective care possible is one of our main goal.


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