Safety, Quality, and Informatics → ESSAY WRITERS

Safety, Quality, and Informatics

Introduction

Some estimates have placed patient safety in the third position among the leading causes of death, only behind heart disease and cancer (Makary & Daniel, 2016). With the increasing population increases and there is more access to healthcare as well as the increasing aging population, there is a greater strain on the system. As a result, patient safety has become a core skill that is sought by various healthcare organizations (Kachalia & Bates, 2014). The intention of safety in our organization is not only to keep patients safe, but all also ensure safety to the staff. The institution has built a culture of safety by starting at the top with the position of vice president of a patient safety playing a key role in setting out the agenda. This office has the responsibility of providing the safety program and ensuring that sustainability of the culture of patient safety has been established. The head of this office is usually a registered nurse with a postgraduate degree and robust experience in clinical practice. This paper will address one patient safety issue; compare the currently used processes for addressing medication errors, in addition to the legal and ethical implications of not addressing the concern. Besides, the essay will look into the use of technology to curb the patient safety issues in addition to discussing the barriers to organizational change and what strategies can be applied to overcome the said challenges.

Patient Safety Issue: Medication Errors

Medication errors are one such critical safety concern for healthcare providers in the entire healthcare continuum. Such errors include prescribing wrong drugs, giving wrong dosage and use of drug combinations that react poorly. The Food and Drug Administration (FDA) acknowledges having received more than 30,000 cases of medication errors beginning 1992 (Agrawal, 2009). However, since the errors and their reporting are done voluntarily, it is highly likely that the number could be significantly higher. Some research has revealed that most of the medication errors fall on the nursing sphere (Kachalia & Bates, 2014). While the said study indicated that the safety of patients is the primary role of nurses, it raised concerns that most institutions do not include the nursing professionals in the decision-making teams and hence there is a little influence in remedying the solution (Kachalia & Bates, 2014). Being aware of the fact that there are occasional prescription errors by the nurses, the next step of dealing with the issue is of paramount significance.

Organizational Processes for Handling Patient safety

The organization that I explored in this assignment has by and largely executed some of the recommendations from the IOM report among the in-house policies that seek to improve patient safety (Agrawal, 2009). The approach that has been given is that of medication errors being a system failure for which a system solution is needed. The institution has recognized the limits of the performance of humans and as such has incorporated a system-oriented approach that has clearly defined and assigned responsibilities and accountability to various departments of the institution. The approach used is multidisciplinary with specific roles being given to the nursing, pharmacy, risk management, quality improvement, administration, and individuals.

What I found to be consistently being emphasized the creation of a non-punitive culture where error reporting and tracking are taken seriously. This compares well with the principles of quality improvement and patient safety since it promotes error reporting as an important aspect of the patient-centered function of the caregiver (Kachalia & Bates, 2014). Reporting ensures that data is collected and used to improve the medication system in the entire organization and among individuals. The organization does have an environment for standardization and medication controls. These are key strategies for patient safety especially when they are designed to have an interdisciplinary collaboration approach. Members in the interdisciplinary partnerships have clearly defined expectations through proper orientation, and periodic training to support those expectations (Kachalia & Bates, 2014). Such expectations can only be supported by organizational structure, leadership, effective communication processes, and support of information exchange and adequate allocation of resources.

Legal and Ethical Consequences of not Addressing Patient-Safety Issues

Full disclosure of medical errors is a huge challenge to the nursing professional and yet it is the right thing to do. It has been established that disclosure and apology does attract low losses in legal and litigation processes. This is beside the ethical and professional requirement that once the errors have been committed, they ought to be reported immediately to enable for remedy of the mishap and ensure the safety of the patient (Kachalia & Bates, 2014). There are laws that seek to protect healthcare practitioners to allow them to apologize freely for the mistakes they commit. This is necessary considering that more than 30% of all malpractice claims are related to drugs (Makary & Daniel, 2016). Medical negligence is the underpinning theory for which a nurse can be sued and found guilty of medical errors. This charge results when the nurse deviates from the professional standards expected of them and in the process causes injury to a patient.

Most medical practitioners appreciate that mishaps ought to be reported to the patients once they happen; however, the reality is that a good number do not disclose such mishaps to the families. Instead, they engage in cover-up schemes in the name of protecting the nurse-patient relationship (Kachalia & Bates, 2014). The decision to conceal this information means the nurse has put personal interest above that of the patients which breaches the ethical requirement of a professional practitioner. Some of the reasons given by the nurses for non-disclosure include legal liability, the possibility of the practice license being revoked, patient distress, damaged reputation and loss of privilege. While the above consequences may be possible for incidences of malpractice, they are just but excuses that should not justify failure to disclose errors (Kachalia & Bates, 2014). By putting ones’ interest before that of the patients, he/she has clearly violated the “do not deceive” moral obligation. Indeed, poor communication and nondisclosure do attract higher legal losses and litigation related to malpractice compared with full disclosure and being responsible for the error caused.

Evidence-Based Interventions to Address Medication Errors

The institute for safe Medication Practices lists the sources of medication errors as resulting from lacking patient information including lab values, diagnoses, and allergies among others prior to dispensing of the drugs (Agrawal, 2009). Unavailable drug information, miscommunication of orders, problems of packaging, labeling and nomenclature of drugs, drug standardization, storage, and packaging are other sources of errors. Besides, it has been established that environmental stress factors like noise, heating and interruptions, limited staff education, limited education for the patients and the processes of quality improvement and risk management are critical aspects that can influence errors and endanger patient safety (Kachalia & Bates, 2014).

To improve medication safety, the health facilities need to acknowledge the above sources of errors and implement significant steps that focus on standardizing and simplifying the medication system process. Fully implementation of the dose unit system which should include proper packaging systems, labeling and order screening is one such process that should be adopted by the hospitals (Agrawal, 2009). There is a need for stressing dose adjustment in older people and children as well as patients with renal impairment. The variety of the devices and equipment used should be limited. When dealing with high-alert drugs, special programs should be developed to ensure that the numbers of possible concentrations of drugs are limited. Moreover, the uses of written guidelines, dose limits, checklists, ensuring special packaging, doing double checks are critical in handling the high-alert drugs.

Evidence-based practice requires that information about drugs is up-to-date especially for infrequently used drugs and the non-formulary medication to be available to clinicians before ordering, dispensing and administering the drugs (Makary & Daniel, 2016). Orientation and periodic staff education to the nurses and clinicians regarding dispensation, administration and monitoring medications as well as the distribution of medication errors from outside organizations is a critical process for improving patient safety (Agrawal, 2009). In the same way, patients should be provided with information during admission, discharge concerning their medications, why they are taking it, and the safety concerns about their use. They should be encouraged to ask questions and the care providers should work to improve patient education especially when they receive more than five types of medication (Makary & Daniel, 2016). Standardizing the prescriptions and communication practices by avoiding the use of dangerous abbreviations, including all elements of the order of strength, dose, frequency and rate are crucial in reducing prescription errors (Kachalia & Bates, 2014). The use of full names and the application of the preprinted orders for non-computerized order systems and the use of metric systems is a standard practice.

How Technology can be used to Improve Patient Safety

The management of medication is a sophisticated process that involves various steps and individuals. With the use of technology, end-to-end management can be achieved where there is a seamless flow of information in the process (Agrawal, 2009). IT takes away the burden of the complexity of clinical decision making and enhances access to information, organize it and identify the associations between the pieces of information. An important tool that helps in this process is the computerized order entry (Radley et al., 2013). It is evident that most errors occur at the prescription stage and using CPOE together with the patient support can help minimize those errors. Some of the common mishaps encountered during prescription include giving a wrong drug, or dosage form, incorrect calculation of the dosage and failing to adjust dosages for children, older persons, and patients with renal diseases (Agrawal, 2009). The system works by ensuring that the order is eligible and includes all the necessary aspects like dosage form, dose, and route. It checks out for any problems like allergies, provides adjustment to dosage calculations, checks for baseline laboratory results and computes lab interactions (Radley et al., 2013). It also provides the prescriber with the most up-to-date drug information.

Dispensing errors can also be reduced by the application of pharmacy dispensing systems which work by packaging and recognizing the drugs by use of bar codes. Further, the bar-coded medications administration (BCMA) systems ensure that the nurse administering medication scans the patients identifying bracelet and unit dose of the drug being given (Agrawal, 2009). The system will alert the nurse of any name, dose route mismatch. Other systems like the personal health records, electronic medication reconciliation, have allowed the medical practitioners easier determination of mismatch and hence reduced errors in medication management (Radley et al., 2013).

Organizational Barriers to Change

The barriers to change for an organization arise from 3 different sources: the targeted institution, the change initiated and the affected employees. The first significant barrier is the resistance to change which comes from the uncertainties and the outcomes that may be caused by the change (Goetsch & Davis, 2014). People fear that they may not cope with the demands of the new environment. Lack of communications skills from the management can lead to people fear venturing into a territory they are unfamiliar with. The management, on the other hand, may be concerned with the lack of sufficient resources to deal with the outcomes of the change. Besides, when an organization has bureaucratic tendencies, it will tend to mandate change where the employees should just take orders without question (Goetsch & Davis, 2014). This management style sees the top making decisions without the input from the bottom and in most cases leads to failed change.

The resources required for change including the financial consideration, the technology required for implementing the change and the failure to clearly define the vision for the organization presents real barriers to change in organizations (Goetsch & Davis, 2014). The push for instant success from the management is a failure to realize that cultural change is not an instant occurrence; instead, it should have realistic timelines and clear targets to allow for progress monitoring and evaluation.

Overcoming the Barriers to change

The first step in overcoming the challenges is realizing the presence, the reasons for their existence and the means of overcoming them. The top management of the organization must be committed to the change and help the course by adopting an effective communication strategy. They must make a case for the benefits of the proposed change and must have the trust of the employees in their action (Goetsch & Davis, 2014). The management must establish beforehand the nature and quantity of resources required to make the change possible. They must also understand why any previously attempted change failed and be open-minded and acknowledge the interdependence of the social systems in the organization.

Encouraging and fostering a flexible and adaptable culture. The management should understand the principles to the resistance of change that includes knowing the reasons for resistance, look at resistance as being a natural response to a contemplated change and this is regardless of whether the change is positive or negative. It is necessary that proper communication of the what, why, how, when of change is done to eliminate the resistance coming from the employees ‘not knowing’. For the ‘not able’ sphere, the management should look to train, educate and acquisition of new skills. For those ‘not willing’ it is recommended that goals, measurements, reward and coaching systems are established and soliciting of feedback (Goetsch & Davis, 2014).

Conclusion

Patient safety forms one of the critical functions of healthcare facilities and indeed, the entire system. While there are many issues that influence patient safety, medication errors rank among the greatest cause of concern for the care providers. Medication errors occur from various sources including poor storage, miscommunication of orders, and lack of patient and staff education among other reasons. Organizations should take a lead role in ensuring that they have an environment in place that encourages medical errors disclosure through creating an interdisciplinary collaboration to address the issue. Nondisclosure of the errors exposes the individual practitioners and the institutions to litigation process and subsequent legal losses in addition to possible revocation of licenses and loss of reputation. The use of IT can help reduce the errors as the information exchange and analysis is done efficiently using the various IT systems. To achieve an organizational change, the top management should be privy to the barriers that face change. Such issues like the budget, IT, financial resources and the human capital required to implement change should be discussed and catered for before beginning implementing change.