Enhancing Quality and Safety

Every step is crucial in healthcare, and medication has essentiality among all steps because any wrong prescription of delivering wrong medication can lead to putting danger someone’s life. Medication errors refer to wrong administration, whether orally or intravenously. For this purpose, healthcare practitioners focus on providing secure and safe medication by enhancing its quality. Hence, this assessment will determine the leading factors that help in patient-safety risk, especially in medication administration. The role of nurses and the best-practice solution will also be considered to improve the quality and reduce costs. Furthermore, stakeholder involvement in this scenario cannot be avoided, so we will emphasize their role in better coordination and driving safety enhancement with medication administration.

Scenario Chosen for Medication Administration

St. Luke’s Magic Valley medical center performed a medication error that caused the 7-month-old infant to die after receiving a dose of saline solution infused intravenously with potassium phosphate, which is used for adult patients (Prentice, 2022). The whole process occurred by mismanagement and misunderstanding as one nurse prepared the adult’s medication which was mistaken by another nurse and administered to the infant. The child’s name was August Elliot, and the prescribed medication for the adult patient was reported in August’s room. When August faced cardiac arrest after 10 minutes of taking medication, the staff started making continuous efforts to save him. After 13 minutes, nurses analyzed the medication and realized that august had injected the cardiac medication. After that incident, the hospital tightened its medication administration, and the investigations were forwarded to the Nation’s top hospital accreditation board and the Twin Falls County Coroner (Ross, 2019). 

The incident takes place because of lacking focus and responsibility by the nurses. The nurses did not perform their duties well and lack of professionalism which caused one family to lose their child. The nurses did not fulfill the SOPs, nor were the policies considered in the hospital.   

Evidence-based and Best Practices 

Despite all other medical errors, medication errors are on the top list and most common in hospitals, impacting thousands of lives and leading them to deaths. The Melnyk et al. study evaluated the healthcare outcomes measures, medication errors, and pharmacy, staffing, and demographic variables. That study demonstrated that 913 hospitals reported medication errors from 1116 hospital population that impacted the patient care outcomes, and each hospital faces 5.07% (Melnyk et al., 2018) medication error each year and experience medication error every 22.7 hours.  

Hence, some best practices were introduced by the American Society of Health-System Pharmacists (ASHP) and the National Center for Biotechnology Information (NCBI) to prevent medication errors in hospitals. The main motive was to figure out at what functions the medication errors occur, so Ordering/prescribing, documenting, transcribing, dispensing, administering, and monitoring are the main functions of medication errors. 

For all these issues World Health Organization (WHO) and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) emphasize providing best practices such as: 

• Verifying orders 
• Usage of barcodes (Cleveland Clinic, 2019)
• Alert on the same name or pronounce medication 
• Double checking each prescribing 
• Implementation of effective warning systems 
• Improve the involvement of patient
• Outlining the issues with details 
• Effective communication among doctors, nurses, and pharmacists
• Document conversation and decisions  (Tariq & Scherbak, 2021)

Safety and quality enhancement require strong insights and decision-making, which exceptional leadership skills can bring. Those leaders with a strong grip on their guts and insights can deliver high-quality results and improve medication administration at the right time for the right person. Medical errors can be prevented through proper monitoring and technological record systems, which reduce the impact of same-name pronunciation errors or bad writing documentation (Tariq & Scherbak, 2021). 

Risk factors 

This unbearable loss was caused by the negligence of duties and roles and the nurse’s reckless actions that led to circumstances where the probability of harming others was extremely high. This incident happened at night, and the hospital was understaffed because the unavailability of nurses at the nurse’s station caused the other nurse to mistook the adult’s medication for children (Herrett v. St. Luke’s Magic Valley, 2018). 

Furthermore, the nurses were burnt out because of exhaustion and overburdened due to workload pressure. This behavior causes them to neglect double-checking the medication and infuse the child with cardiac medication. The nurses were mentally and physically exhausted, and this condition generated unbearable loss and impacted the hospital’s reputation as well, so these risk factors like 

• Understaffing 
• Physically and mentally exhaustion
• Negligence of duties    

Impacted someone’s life and the hospital’s image. 

Organizational Interventions to Promote Patient Safety 

Proper strategies, implementations, and coordination of nurses with medication administration can help promote patient safety measures. Most professionals do not consider patient instincts and leave their views outside, which impacts their safety protocols. However, it is required to engage patients by listening to their concerns, and driving their satisfaction should be the basic patient safety initiative (Haugen et al., 2019). Doing so will inform the patient and their family about the treatment concerns and avoid medical errors. The basic strategies can be implemented to improve patient safety and nurse coordination, improve medication administration and reduce costs.  

• Reducing communication gap 
• Understanding proper abbreviations to avoid wrong prescribing 
• Realization of roles and responsibilities 
• Promoting experience and skilled professionals (Tariq & Scherbak, 2021)
• Allocation of enough staffing to avoid the staffing shortages 
• Awareness of guidelines and hospital policies 
• Encouragement to patient families and caregivers for more engagement 
• Attending timely patient on scheduling 

For example, after this incident, the hospital applied serious interventions to promote safety measures, such as imposing medication administration guidelines. Furthermore, they applied training sessions for nurses to alert them regarding their roles and responsibilities and make them adopt the habit of double-checking the prescribed medicine and details of patients. They included the services of the contract with patients, food services, cultural and language services, and spiritual care in their guideline procedures. Furthermore, they also settle the budget for providing these services; violating any nurse’s duties will cause them to fill the penalties. 

Nurse’s Help and Coordination in Care to Increase Patient Safety

Nurses are a critical asset to the healthcare organization; despite their duties for patient care safety, they are also responsible for coordinating with stakeholders to drive quality and safety enhancement with medication administrations. Nurses should also focus on care coordination to enhance patient outcomes with lower costs. Sharing knowledge and insurance of transition of care is necessary for increasing patient safety. The stakeholders in this scenario will be pharmacists, medical administrates, healthcare providers, and patients with whom nurses will coordinate. The inter-professional team also includes the clinicians and patient administrators to improve the communication chain and educate the caregivers to decrease medication errors (University of Southern Indiana, 2019). 

Furthermore, nurses’ collaboration with stakeholders also reduces costs as they will get the proper understanding of treatment which causes them to spend right on the demanded treatment. It will also help the hospital administration to save time and medicines from prescribing them to the patients (Lieder, 2020). 

Role of Stakeholders

Stakeholders are those who participate in the organization, and in healthcare, medical professionals, pharmacists, educators, entrepreneurs, educators, researchers, leaders, managers, policy-makers, clinical assistants, clinicians, and patients are healthcare professionals. Stakeholders are responsible for resource allocation, skills enhancement, and sharing knowledge at maximizing level to mitigate medical administration errors. The entire stakeholder’s involvement is necessary to produce the best outcomes; however, training and guideline implication is required. The World Health Organization (WHO) (Haugen et al., 2019) has announced all the implications necessary to implement in the healthcare system to improve the decision’s impact and ethical consideration. Awareness of roles and responsibilities reduces medical errors and improves the quality of services that lead to secure patient care (Sittig et al., 2018). 

Driven healthcare quality demands stakeholders’ involvement and improved nurse coordination for care. A nurse’s improved behavior can lead the patient to gain confidence in self-managing care and reduce the overall charges, significantly increasing the chance of survival. Improving population health and patient experience also counts in the procedure to reduce the per capita costs. 

Conclusion

Hence, enhancing quality and safety in healthcare medication administration requires implementing guidelines and care transitions. In the assessment, we determine the St. Luke’s Magic Valley case, where mismanagement of medication administration causes the death of the seven-month-old infant. However, after analyzing the situation, we need strategies to improve medication administration and reduce errors. The evidence-based solutions were imposed, and organizational interventions were proposed to determine the nurse’s coordination with stakeholders to increase patient safety. At last, we identified the stakeholders essential in healthcare systems who helped drive the quality and engage the patient and staff for better collaboration.  

References 

Cleveland Clinic. (2019). Patient Safety Program | Cleveland Clinic. Cleveland Clinic. https://my.clevelandclinic.org/departments/patient-experience/depts/quality-patient-safety/patient-safety-program

Gadsby, G. (2022). Are prescription errors classified as medical negligence? Gadsby Wicks. https://www.gadsbywicks.co.uk/insights/medical-negligence/are-prescription-errors-classified-as-medical-negligence

Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019). Impact of the World Health Organization Surgical Safety Checklist on Patient Safety. Anesthesiology, 131(2), 1. https://doi.org/10.1097/aln.0000000000002674

Herrett v. St. Luke’s Magic Valley Regional Medical Center, Ltd. Respondent’s Brief Dckt. 44567. (2018). Herrett v. St. L . St. Luke’s Magic V s Magic Valley Regional Medical Center y Regional Medical Center, Ltd. Respondent’s Brief Dckt. 44567. Idaho Law. https://digitalcommons.law.uidaho.edu/cgi/viewcontent.cgi?article=7980&context=idaho_supreme_court_record_briefs

Lieder, T. (2020). 10 Strategies to Reduce Medication Errors. Drug Topics. https://www.drugtopics.com/view/10-strategies-reduce-medication-errors

Melnyk, B. M., Orsolini, L., Tan, A., Arslanian-Engoren, C., Melkus, G. D., Dunbar-Jacob, J., Rice, V. H., Millan, A., Dunbar, S. B., Braun, L. T., Wilbur, J., Chyun, D. A., Gawlik, K., & Lewis, L. M. (2018). A National Study Links Nurses’ Physical and Mental Health to Medical Errors and Perceived Worksite Wellness. Journal of Occupational and Environmental Medicine, 60(2), 126–131. https://doi.org/10.1097/jom.0000000000001198

Prentice, G. (2022). St. Luke’s: Nurse’s Medication Error Resulted in Child Fatality. Idaho Press. https://www.idahopress.com/boiseweekly/news/citydesk/st-lukes-nurses-medication-error-resulted-in-child-fatality/article_9615fc57-09a8-5f40-9673-2493db440c0d.html

Ross, M. (2019, March). 6 Medication Error Stories That Made Headlines. Cureatr.com; Cureatr Inc. https://blog.cureatr.com/6-medication-error-stories-that-made-headlines

Sittig, D. F., Belmont, E., & Singh, H. (2018). Improving the safety of health information technology requires shared responsibility: It is time we all step up. Healthcare, 6(1), 7–12. https://doi.org/10.1016/j.hjdsi.2017.06.004

Tariq, R. A., & Scherbak, Y. (2021). Medication dispensing errors and prevention. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

University of Southern Indiana. (2019, July 12). What Nurses Need to Know About Care Coordination. University of Southern Indiana. https://online.usi.edu/degrees/nursing/rn-to-bsn/nurses-need-to-know-care-coordination/