Question

Medication Errors Questions
Review the performance dashboard below for General Medical Center, as well as relevant local, state, and federal laws and policies. Then, write a report for senior leaders in the organization that communicates your analysis and evaluation of the current state of organizational performance, including a recommended metric to target for improvement.

Dashboard Evaluation metrics at General Medical Center for medication errors in the different units of the hospital. In the Medical and Surgery department, medication error for 2015 was 4 and it increases in 2016 to 8. The labor and delivery department in 2015, there were 5 medical errors found while in 2016 there was no record of medical error. The Orthopedics department in 2015 had 2 medication errors and in 2016 they had the same amount of medication error. The Bariatric Services has 7 medication errors in 2015 and in 2015 there were 7 medication errors.

1.) Analyze the effects of health care policies, laws, and regulations on organizations, interprofessional teams, and personal practice for Medication Errors.

2.) Analyze challenges that meeting prescribed benchmarks can pose for a health care organization or an interprofessional team (Medication errors).

3.) What are the specific challenges or opportunities that the organization or interprofessional team might have in meeting the benchmarks? Consider organizational resources such as staffing, finances, physical space and support services? What about the cultural diversity of the organization and the community? Please add a heading that reflects this criteria.

4.) Advocate for ethical action in addressing a benchmark underperformance, directed toward an appropriate group of stakeholders. Describe specific evidence-based best practices to reduce Medication Errors. Review CDC, AHRQ or the National Quality Forum for best practices.

5.) What are the local, state and federal healthcare policies and laws that set these benchmarks?

6.) Evaluate a benchmark underperformance in a heath care organization or an interprofessional team that has the potential for greatly improving overall quality or performance.

7.) What are the consequences can occur if the benchmark is not met?

8.) What are various methods of communicating with policy makers, stakeholders, colleagues, and patients to ensure that communication in a given situation is professional, clear, efficient, and effective?

Answer 1

A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention.

1)Medical errors are a serious public health problem and a leading cause of death. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.Healthcare providers want to improve outcomes while reducing the risk of patient harm. Despite provider best efforts, medical error rates remain high with significant disability and death. Preventable medical errors contribute substantially to healthcare costs, including higher health insurance costs per person expenses.

The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers

• Identify patient safety dangers and risks.

• Identify patients correctly by confirming the identity in at least two ways

• Improve communication such as getting test results to the correct person quickly

• Use medicines correctly and safely, double-checking labeling and correctly passing on patient medicines to the next provider.

• Label all medications, even those in a syringe. This should preferably be done in the area where the medications are prepared.

2)The problems, causes, and weaknesses of current medication safety practice, participants pointed out many factors such as the limited use of technology, unrestricted public access to medicines from various hospitals and community pharmacies, communication gaps between healthcare institutions, and the lack of rigorous medication safety programs in hospitals.

Lack of trained staff in medication safety, such as medication safety officers; the unavailability or non-adherence to policies and procedures; and the unavailability or non-adherence to guidelines ensuring medication safety, such as the lack of proper labeling of medications, lack of standardized look-alike and sound-alike lists of drugs, and lack of implementation of medication reconciliation.

A major contributor to prescribing errors was physicians’ illegible handwriting. They suggested that computerized provider order entry (CPOE) might alleviate the problem. However, they recognized that a limited number of hospitals had adopted CPOE, and believed that those hospitals had not benefited as much as might be expected from CPOE. Pharmacy-information and bar-coding systems were also mentioned as important technologies that are lacking in most healthcare institutions.

3) Challenges faced by institutions in meeting the benchmark (medication Error)

• Communication gaps between healthcare institutions

• Absence of medication safety programs in hospitals

• Underreporting of medication errors and ADRs

• Multilingualism and different backgrounds

Participants highlighted issues relating to the cultural diversity and multilingualism among healthcare professionals who come from different backgrounds and different healthcare systems. Participants emphasized the impact on communication, especially with verbal orders.

• Culture of safety

• Communication between healthcare professionals

• Work load or inadequate number of staff

4)

• Research

• Continuous education and competency assessment

• Establish a cultural safety

• Need for wider use of technology

• Need for national initiatives and support from the national accreditation body

National Quality Forum List of Serious Reportable Events , Patient death or serious injury associated with a medication error.

5)

• National Accreditation Body
• Joint commission International
• Hospital policies on Medical Error

6) Study reported that the main barriers to medication error reporting include organizational factors, such as fear of appraisal from management and/or administration; information gaps, such as lack of definition or standards for reporting medication errors; and the inability to recognize or identify medication errors

7)The range of consequences from medication error effects runs from no notable effects to death. In some cases, it can cause a new condition, either temporary or permanent, such as itching, rashes, or skin disfigurement. Although uncommon, medication errors can result in severe patient injury or death.

8)

Continuous education and continuous competency assessments focusing on medication safety are needed to enhance the current practice and help train healthcare professionals about best practices in medication safety.Increasing the awareness of healthcare professionals about the trend of medication errors and the need for a unified database to ensure continuity of care.