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Introduction
Schnipper (2012) believes that medication-related errors are among the main challenges in primary care. More so, medication-related errors are more profound in the outpatient setting, where medication reconciliation challenges the reduction of medication errors. The occurrences of medication-errors have increased medication-related morbidity and mortality. In fact, Schnipper (2012) reports that medication-related morbidity and mortality costs about $76 billion yearly. The main causes of medication errors are medication discrepancies and inconsistencies in prescription regimens (Ulfvarson, 2010, p. 571).
This paper analyses an incident involving a medication-related error that occurred in an undisclosed health care facility. The analysis encompasses the main details of the case and a personal analysis of the incident. Thereafter, to have a broader theoretical understanding of the problem, this paper conducts a literature review that addresses medication errors. Comprehensively, these analyses provide the right framework for developing different interventions, which strive to respond to the problem. Finally, this paper outlines two technology-based interventions that help reduce medication errors. The evaluation section provides a summary of the findings.
Literature Review
Albeit medication errors may occur at different stages of a patients treatment process, Mahmood (2012) believes that the ordering and monitoring stages are the most common stages for the occurrence of medical errors. Nonetheless, many factors cause medical errors. For example, ordering errors vary. They include wrong dose, prescribing drugs that interact with other medication and wrong choice (Mahmood, 2012, p. 431). Muñoz (2010) believes that the best way to prevent the occurrence of a medication error is to understand when it occurs and to establish the best control measures for preventing its occurrence. Many researchers say medication errors occur during prescription, but others claim that such errors may occur at any stage of the drug administration process (Mahmood, 2012). The latter group also identifies the transcription, dispensing, and administration phases as crucial stages where medication errors may occur (Muñoz, 2010).
Interestingly, health care facilities that have adopted an automated system for drug administration report low levels of medication errors. Studies that support this observation also explain the reasons for the occurrence of such low errors. Indeed, they show that administration errors and the non-compliance with the standards of prescribing drugs account for the strongest causes of medication errors (Belén, 2011). For example, Belén (2011) claims that administration errors account for about 19% of medication errors. In addition, when Belén (2011) compares the nature of medication errors, he says that they all show a high rate of non-compliance with international standards of drug administration. A common type of medication error is ambiguous dosages. Belén (2011) says the solution to preventing potential adverse drug events (and most medication errors) rest in employing online personal health records. This solution improves medication accuracy and safety.
Using online personal health records mirror other suggestions by different researchers like Muñoz, (2010) who recommends the use of computerized prescription methods to overcome some of the causes of medication errors. Some of these causes include simple procedural mistakes (like using non-standardized names, using unclear medical orders, and the failure to observe international standards for drug administration). Automating the drug administration process easily prevents most of these errors.
Case Study
An incident happened in one health care facility where I witnessed the consequences of a medication error. The incident involved a patient, Ms. Brown Christine who stemmed from a family history of cardiac problems. Ms. Brown was a single mother of two children. She was also aged 35 years and worked as a tour guide operator in the city. Seven years ago, doctors diagnosed Ms. Brown with high blood pressure after she reported to the hospital after suffering a blurred vision. The doctor prescribed an assortment of medications to the patient, but she failed to complete her medication, because they left her drained of energy. A few years later, Ms. Brown complained of short breaths, swollen legs, swollen ankles, and breathlessness. The doctor put the patient on Coumadin.
During the day of the incident, the nurses drew her blood for monitoring, through the International Normalized Ratio (INR). The doctor wanted to know how much of the drug was in her system so that he could increase (or decrease) the patients dosage. Unfortunately, the healthcare practitioner fed a wrong assessment into the patients record. The wrong assessment showed that the patients INR was low. Consequently, the doctor increased the patients drug dosage. The patient later developed Coumadin toxicity and the doctors had to hospitalize her. She was bleeding from her eyes and nose. Emergency nurses and doctors had to save her life.
Analysis
The underlying cause of the above incident was poor medical recording. From this error, the doctor prescribed a higher dosage than what the patient should have received. Indeed, from the understanding of medication-error risk posed to the patient, every concerned party was wary of the consequences of making another erroneous medical assessment. From this realization, it is safe to say the reaction of the medical practitioners was adaptive.
Interventions
Computerized Physician Order Entry (CPOE)
(What) The CPOE method solves most adverse patient events. Mainly, the CPOE method works by centralizing the charting functions for all physicians to have a centralized point of reference, while making medical decisions regarding a patients medication. (Who) Since the CPOE is mainly an administrative tool, hospital administrators should introduce this method. They should also ensure that all stakeholders embrace its adoption and support its implementation. (When) The best time for adopting the CPOE method is when the right conditions arise. In other words, the hospital administrators should introduce this method when they gain stakeholder buy-in. The immediate introduction of this technological tool may prevent the further occurrence of medication errors. (Where) The introduction of the CPOE method should reform the drug administration system of the health care facility. Here, there is a special emphasis to confine the application of the CPOE method to the operations of the health care facility only.
Computerized Decision Support Systems (CDSS)
(What) The CDSS tool is crucial in the prevention of medication errors because it detects possible drug interactions and identifies the right dosing schedules. (Who) The main difference between this tool and the CPOE method lies in its ability to influence the physicians decision-making process. This influence stems from its ability to notify a physician about the correct lab results that they use in the decision-making process (American Academy of Orthopedic Surgeons, 2012). With this capability, the CDSS tool may have prevented the recording of erroneous results, as witnessed in the case study above. (When) Like the CPOE method, the best time for adopting the CDSS method is when the right conditions arise. In other words, the hospital administrators should introduce this method when they gain stakeholder buy-in. The immediate introduction of this technological tool may prevent the further occurrence of medication errors. (Where) Like the CPOE method, the introduction of the CDSS method should reform the drug administration system of the health care facility. Specifically, the CDSS method should apply to all drug administration procedures in the health care facility.
Evaluation
Medication errors are among the most serious types of medical errors. Their detection and prevention therefore form a critical part of improving patient safety. This paper demonstrates the potential for adopting technological interventions to prevent and detect these errors. Indeed, as affirmed by the researchers sampled in the literature review section, the prevention of a medication error lies in the adoption of technological solutions. The adoption of technological solutions not only improves a patients safety, but also increases the quality of care. Similarly, this paper proposes several technology-based intervention methods as the best methods to prevent the occurrence of medication errors (as described in the case study analyzed above). Besides the adoption of technology-based interventions, this paper highlights the importance of embracing adaptive behaviors as an issue resolution method so that similar medication errors do not occur in future. Therefore, the key to preventing most medication errors depend on the adoption of technology-based tools, such as, the CPOE and CDSS. Nonetheless, introducing CPOE and CDSS tools require a huge capital investment. This capital investment is required for purchase and installation of new equipment (Emerald Group, 2012, p. 1). More resources are also required to train the healthcare practitioners to use the new equipment. Besides these challenges, healthcare administrators may face another challenge of experiencing workers objections to the new interventions. In other words, the hospital staff may oppose the adoption of such interventions. It is therefore crucial for hospital administrators to involve the health care practitioners before introducing such interventions.
Comprehensively, adopting the above technology-based interventions (successfully) mainly rely on the success of training medical practitioners to implement these interventions. Furthermore, determining how easy these technological interventions merge with the existing tools and protocols (within the healthcare facility) determines the success of the interventions. Generally, the new interventions (and the existing tools and protocols within the institution) should both provide a comprehensive quality improvement program. These recommendations support the stipulation by the American Academy of Orthopedic Surgeons (2012), which upholds the need for maintaining the highest standards of safety in health care institutions. These recommendations therefore encompass a culture of safety in the healthcare environment.
Poster Presentation
Problem Issue
Compared to other leading causes of death in the health care sector (such as, motor vehicle accidents and breast cancer), medical errors account for the highest cause of death.
Literature Support
The inconsistencies and discrepancies that cause medication errors subdivide into smaller procedural errors, such as, wrong dosage, errors of omission, order duplication, wrong drug administration, prescription of wrong formulas (and the likes). These errors contribute to the prevalence of medication errors, but as outlined in the graph below, wrong dosages account for the highest causes of medication errors.
Administrative problems also account for the occurrence of medication errors. Some of these administrative problems include understaffing, vague communications, overworking nurses (fatigued nurses) and the failure to use proper drugs (similar medication bottles). The figure below outlines these problems
Some adverse drug events are preventable, while others are non-preventable. As outlined in the diagram below, non-preventable drug events account for most adverse drug reactions.
Ideas for Correcting the Problem
Technological interventions (CPOE and CDSS) improve the safety management process to provide a well-coordinated care process that provides positive health outcomes as outlined below.
These positive health outcomes reduce the occurrence of medication errors.
References
American Academy of Orthopedic Surgeons. (2012). Prevention of Medication Errors. Web.
Belén, A. (2011). Comparison of medication error rates and clinical effects in three medication prescription-dispensation systems. International Journal of Health Care Quality Assurance, 24(3), 238 248.
Emerald Group. (2012). Ireland Research demonstrates the importance of accurate electronic records for improving patient safety. International Journal of Health Care Quality Assurance, 25(3), 1-2.
Mahmood, A. (2012). Long-term care physical environments effect on medication errors. International Journal of Health Care Quality Assurance, 25(5), 431 441.
Muñoz, A. (2010). Medication error prevalence. International Journal of Health Care Quality Assurance, 23(3), 328 338.
Schnipper J. L. (2012). Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. Am Med Inform Assoc, 19(5), 728 734.
Ulfvarson, J. (2010). Medication reviews with computerized expert support: Evaluation of a method to improve the quality of drug utilization in the elderly. International Journal of Health Care Quality Assurance, 23(6), 571 582.
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