Analyze a Current Health Care Problem or Issue
NHS-FPX 4000 Assessment 4
Name
Capella University
NHS4000: Developing a Health Care Perspective
Prof.
Februray, 2024
Analyze a Current Health Care Problem or Issue
Medication errors significantly threaten patient safety in the ever-changing healthcare field. Medication errors refer to when prescribing, dispensing, administering or monitoring medication. These mistakes can be very serious, even leading to patient harm and death. Improving healthcare services requires addressing errors effectively. This is essential for ensuring the safety and quality of care provided. The analysis explores the complex issue of medication errors, looking at their causes, effects, and possible solutions (Wimmer et al., 2023). The importance of healthcare organizations needs to be stressed while establishing a strong culture of safety, focusing on both medication and patient safety and the ethical foundations of these solutions. Through this examination, valuable insights are provided that can enhance healthcare practices and improve patient outcomes.
Errors within the healthcare system, ranging from delivery mistakes to systemic flaws, pose significant risks in the rapidly changing healthcare landscape. These errors can lead to serious patient harm or other negative outcomes, including direct mistakes by frontline staff and indirect systemic issues (Pruitt et al., 2023). A holistic approach involving various healthcare practices and processes is required to address these challenges. It’s important to recognize that not every adverse outcome is due to errors. Specifically, preventable adverse events are often linked to medical mistakes. The culture within the healthcare sector often discourages professionals from reporting errors, which creates a fear of retribution or reputation damage. This environment hinders the identification and correction of errors, which increases the likelihood of further adverse events.
A shift towards a blame-free culture that encourages error reporting is essential to promote quality improvement and enhance patient safety. As a professional similar to a medical transcriptionist, I understand the critical nature of accurate healthcare documentation. Mistakes in transcribing, such as recording the wrong medication dosage, can have severe implications for patient safety. This perspective highlights the interconnected roles within the healthcare system and their collective impact on ensuring patient safety. It emphasizes diligence, thoroughness, and continuous improvement in all healthcare processes (Bell et al., 2023).
Elements of the Medication Errors
Medication errors are a major concern in healthcare settings. These errors can happen at different stages of the medication process. The stages include prescribing, dispensing, administering, and monitoring. In prescribing, the physician determines the medication, dosage, and route of administration. In dispensing, the medication is prepared and delivered to the patient. In administering, the medication is given to the patient. And in monitoring, the patient’s response to the medication is assessed. Medication errors can have serious consequences for patients, such as adverse reactions, prolonged hospital stays, and even death. Therefore, healthcare professionals must stay alert and take steps to minimize the risks of medication errors. Common types of medication errors include:
- Incorrect patient identification.
- Wrong medication or dosage.
- Adverse drug events.
- Errors in the timing or rate of administration.
- Use of expired products.
Failure to consider patient-specific factors like allergies or liver and renal function. These errors can result from various factors, such as distractions, illegible handwriting, workload, similar drug names, and lack of proper communication protocols. The consequences of medication errors are significant and costly in terms of patient health and the healthcare system (Jin et al., 2020). Thousands of deaths in the United States annually are attributed to medication errors, costing more than $40 billion. These errors can also decrease patient satisfaction and trust in the healthcare system.
Addressing this issue requires a comprehensive approach involving various healthcare professionals. Effective interventions identified in a systematic review include computerized physician order entry (CPOE), automated medication distribution systems, pharmacist involvement in medication matching, and prescriber education. These interventions have shown promise in reducing errors related to prescribing and administering medications. However, there still needs to be more effective strategies for reducing errors related to the supply of medications (Dhamanti, et al., 2021).
The challenge in solving medication errors lies in their complex nature involving human and system factors. Therefore, future research and interventions should focus on interdisciplinary collaborative approaches that include physicians, pharmacists, and nurses working together to reduce these errors. Medication errors are critical in patient safety, with multiple causes and significant consequences. Addressing them effectively requires a blend of technological solutions, educational efforts, and systemic changes in healthcare practices.
Analysis of Medication Errors Including Preventable Adverse Effects
Medication errors are incidents that can be prevented, and they occur when inappropriate medication is used or when the patient is harmed. At the same time, medicine is being controlled by healthcare professionals, patients, or consumers (Setareh et al., 2022). One of the critical aspects of this issue is the preventable adverse effects that arise when patients take the wrong medication or incorrect dosage. Such errors can have serious consequences, ranging from patient harm to death, as highlighted by numerous studies on PubMed and reports by StatPearls on NCBI Bookshelf.
Involved Parties and Root Causes
The range of medication errors involves several healthcare professionals, including physicians, pharmacists, nurses, and patients. The reasons behind these errors are multifaceted and include human factors such as distractions and workload, systemic issues such as similar drug names and packaging, and technological errors in electronic prescribing systems.
Context and Impact of Medication Errors
The healthcare industry faces a serious challenge due to medication errors threatening patient safety. The complex nature of modern medication management and the wide variety of drugs available further complicate efforts to prevent such errors. These errors significantly impact the patient’s safety, health and trust in the healthcare system (Tapuria et al., 2021). Moreover, they result in substantial financial burdens. PubMed research has also highlighted the gravity of this issue.
NHS-FPX 4000 Assessment 4 Analyze a Current Health Care Issue or Problem
Populations Most Affected
Some groups of people are at a higher risk of being harmed by medication errors than others. The elderly, who are often taking many different medications, and children, who require precise doses, are especially vulnerable, and mistakes can have more serious consequences. Patients with chronic conditions are also at a greater risk because their medication regimens are usually more complex.
Mitigation Strategies and Solutions
To reduce medication errors, several interventions have been suggested. One key strategy is Computerized Physician Order Entry, which helps in electronic prescribing and can help reduce errors due to handwriting and manual data entry. Pharmacist reviews are also critical in providing an additional layer of verification and expertise in medication management. Patient education is another vital component that ensures patients understand their medications and how to take them correctly (Wimmer et al., 2023). Developing systems to double-check medication orders and dosages can also help prevent errors. These interventions align with the suggested medication and patient safety keywords and emphasize a holistic approach to reducing medication errors.
Potential Solutions for Medication Errors and Ethical Considerations
To avoid medication-related mistakes, it is essential to use a combination of technological, educational, and procedural interventions. One way is integrating Electronic Health Records (EHR) and Computerized Physician Order Entry (CPOE) systems. Doing this can significantly reduce errors caused by manual data entry and illegible handwriting. These technologies streamline the medication prescribing and dispensing processes, enhancing accuracy and efficiency (Abraham et al., 2020). Pharmacists can also play an active role in medication management by performing medication reconciliation and review. This can significantly mitigate risks, especially in complex polypharmacy cases or patients with multiple comorbidities.
It is also essential to standardize protocols and checklists for prescribing, dispensing, and administering medication. Hospitals can make healthcare safer by using a consistent approach. This is especially important in high-risk areas like operating rooms or intensive care units. In addition, educating patients about their medications, including the correct dosages, timing, and potential side effects, is essential. Educating patients can help them adhere to their medication regimens and avoid errors. Engaging patients in discussions about their medications also respects their autonomy in the healthcare decision-making process (Bell et al., 2023). It is important to have regular training and awareness programs for healthcare professionals to maintain a high standard of care. Consistent education on medication safety, updates on best practices, and training in new technologies keep healthcare workers up-to-date with safe medication practices and advancements in the field.
Consequences of Ignoring Medication Errors
It is crucial to address medication errors to prevent adverse drug events that can cause patient morbidity and mortality. These events are preventable, and if left unaddressed, they can have dire consequences. The financial impact on the healthcare system can be significant, as additional treatments, legal liabilities, and extended hospital stays can incur substantial costs. Furthermore, medication errors can severely damage the trust between patients and the healthcare system, leading to a decline in the quality of care patients perceive (Wimmer et al., 2023).
Ethical Considerations in Addressing Medication Errors
The principles of beneficence, non-maleficence, autonomy, and justice are vital in addressing medication errors. Healthcare providers demonstrate beneficence by striving to reduce these errors and actively promoting the well-being and safety of patients. By adhering to the principle of non-maleficence, they seek to prevent potential harm from medication errors and do no harm. Respecting patient autonomy through education and engagement ensures that patients are well-informed and active participants in their healthcare. Lastly, justice is served by ensuring equitable access to safe and effective medication practices for all patients, irrespective of their background or circumstances (Tariq et al., 2023). To address medication errors, we need a multifaceted approach that involves technological integration, professional vigilance, patient education, and a strong commitment to ethical principles. Addressing this issue is important for patient safety and healthcare system integrity. Failure to do so can have extreme consequences, making it urgent to find solutions.
Ethical Implications of Implementing a Potential Solution
Implementing Computerized Physician Order Entry (CPOE) systems is a potential solution to medication errors. However, it is important to consider ethical principles while implementing these systems. The main principle behind the use of CPOE is goodwill, which aims to enhance patient safety by reducing the risks of medication errors. These systems significantly reduce the chances of errors associated with manual prescribing, such as incorrect dosages or medications, by automating the prescription process (Tariq et al., 2023). This error reduction aligns with the principle of nonmaleficence, ensuring that healthcare providers do not harm their patients.
The implementation of CPOE systems also touches upon the principle of autonomy. By improving the accuracy of medication orders, patients are more likely to receive appropriate treatment, thus supporting their right to effective and safe healthcare. Furthermore, when integrated with patient education initiatives, CPOE systems can empower patients to understand their treatment plans better, thus actively participating in their healthcare decisions. Justice is another critical ethical principle in the context of CPOE implementation (Wimmer et al., 2023). These systems must be accessible and beneficial to all patients, ensuring equitable healthcare delivery. This means that the benefits of reduced medication errors should not be limited to certain patient groups or healthcare settings but should be universally accessible to enhance the overall quality of care.
NHS-FPX 4000 Assessment 4 Analyze a Current Health Care Issue or Problem
Pros and cons for the Solution
The implementation of CPOE systems comes with its own set of challenges. These systems have their benefits, such as improved medication safety and efficiency in the prescribing process. They can reduce the potential for human error and streamline healthcare workflows. However, there are some drawbacks as well. The costs associated with setting up and maintaining these systems can be significant. Healthcare professionals need extensive training, and there is a risk of technical issues or system failures that may disrupt healthcare services. To successfully implement CPOE systems, it is essential to adhere to ethical principles (Wimmer et al., 2023). This requires ensuring equitable access to the technology, providing comprehensive training to healthcare professionals to prevent new types of errors, and involving patients in the process to respect their autonomy and rights. It is important to weigh the initial challenges and costs against the long-term benefits of improved patient safety and healthcare quality.
Conclusion
Medication errors are a consequential healthcare problem that can harm patients. To prevent these errors, healthcare professionals need an approach that includes technology, oversight, and patient education. They can reduce the occurrence and impact of medication errors. However, implementing Computerized Physician Order Entry systems also presents challenges that must be addressed (Tariq et al., 2023). However, these systems align with key ethical principles in healthcare, such as beneficence, non-maleficence, autonomy, and justice, making them a viable solution to the widespread issue of medication errors. Effective implementation of healthcare systems requires careful planning, ethical considerations, and ongoing evaluation. This ensures that healthcare providers’ and patients’ needs are met, resulting in safer and more efficient healthcare delivery.
NHS-FPX 4000 Assessment 4 Analyze a Current Health Care Issue or Problem
References
Abraham, J., Kitsiou, S., Meng, A., Burton, S., Vatani, H., & Kannampallil, T. (2020). Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews. BMJ Quality & Safety, 29(10), 1–2. https://doi.org/10.1136/bmjqs-2019-010436
Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17-18), 5445–5460. https://doi.org/10.1111/jocn.16620
Dhamanti, I., Kurniawati, E., Zairina, E., Nurhaida, I., & Salsabila, S. (2021). Implementation of computerized physician order entry in primary care: A scoping review. Journal of Multidisciplinary Healthcare, 14, 3441–3451. https://doi.org/10.2147/JMDH.S344781
Jin, M. X., Kim, S. Y., Miller, L. J., Behari, G., & Correa, R. (2020). Telemedicine: Current impact on the future. Cureus, 12(8), e9891. https://doi.org/10.7759/cureus.989
Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D. N., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating electronic medication administration record and bar-coded medication administration usability. Applied Clinical Informatics, 14(1), 185–198. https://doi.org/10.1055/s-0043-1761435
Setareh, S., Rabiei, R., Mirzaei, H. R., Roshanpoor, A., & Shaabani, M. (2022). Effects of guideline-based computerized provider order entry systems on the chemotherapy order Process: a Systematic Review. Journal of the Society for Medical Informatics of Bosnia & Herzegovina, 30(1), 61–68. https://doi.org/10.5455/aim.2022.30.61-68
Tapuria, A., Porat, T., Kalra, D., Dsouza, G., Xiaohui, S., & Curcin, V. (2021). Impact of patient access to their electronic health record: systematic review. Informatics for Health & Social Care, 46(2), 192–204. https://doi.org/10.1080/17538157.2021.1879810
Tariq, A., Vashisht, R., Sinha, A., (2023). Medication dispensing errors and prevention. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/Wimmer, S., Toni, I., Botzenhardt, S., Trollmann, R., Rascher, W., & Neubert, A. (2023). Impact of a computerized physician order entry system on medication safety in pediatrics-The AVOID study. Pharmacology Research & Perspectives, 11(3), e01092. https://doi.org/10.1002/prp2.1092
