Introduction
RCA is predicated on the premise that good management involves more than simply resolving existing problems; it demands identifying ways to avert them (Latino et al., 2019). RCA assists businesses in avoiding the inclination to focus exclusively on a particular component to get at the quickest remedy. Additionally, it is beneficial to avoid addressing symptoms instead of the root causes of a problem or incident.
In healthcare settings, practitioners can use RCA to conduct retrospective studies of occurrences involving patient injury or unfavorable consequences to determine and treat the underlying sources (Latino et al., 2019). By identifying the underlying etiology of an incident, practitioners can increase patient safety and avoid future injury. Accordingly, this presentation aims to describe and analyze medication administration errors as a primary safety issue in hospitals and develop an improvement plan to address this concern.
Analysis of Medication Errors
Annually, nearly 400,000 hospitalized individuals suffer some form of avoidable injury. At the same time, over 100,000 individuals die as a consequence of medical errors in clinics and hospitals annually (Rodziewicz et al., 2021). Ultimately, medication errors cost the US healthcare system about $177 billion per year (Haroutounian, 2019). Errors in prescribing medications may also include an incorrect choice of the drug, its administration in an inadequate dose, wrong dosage regimen, and duration of therapy.
Correspondingly, pharmacy personnel may misread the prescription, resulting in the issuance of the erroneous medicine or dosage. Likewise, errors may result from incorrect patient guidelines or inappropriate medication administration by a healthcare practitioner or patient. Sometimes, incorrect drug storage by a pharmacist employee or a patient, may cause the expiry or a reduction in the drug’s potency (Mazhar et al., 2018). Other errors may result from incorrect delivery of medication to the patient (Haroutounian, 2019). Additionally, faulty transfer of prescription details between various manufacturers may cause medication errors.
Moreover, errors can also occur when patients are transferred from one doctor to another or from one hospital to another, due to erroneous transfer of data in the prescription. On many occasions, these mistakes resulted in fatal outcomes and lead to lawsuits against the hospital, which underscores the need to prevent them. Electronic drug dispensing systems reduce the likelihood of such errors as the systems are automated (Strom et al., 2019).
Application of Evidence-Based Strategies to Reduce Medication Errors
Research has shown that it is possible that punishing employees for making mistakes will limit the number of errors they disclose (Rodziewicz et al., 2021). However, failing to address the issue raises the risk of further adverse outcomes, which puts additional people at risk. As such, giving doctors and pharmacists objective and impartial information on the possible side effects of drugs is a proven technique for reducing medication errors. Data about interactions between drugs and physiologically active substances is also included in this information (Alazani et al., 2019). Another feasible strategy is to improve the safety control system for medicines at all administrative levels in clinical and preventive facilities (Strom et al., 2019).
Consequently, it is important to implement new techniques for detecting unfavorable adverse reactions, like close surveillance, in addition to the use of spontaneous notifications. Likewise, assessment of morbidity and mortality statistics, as well as the dependency of pharmacotherapy problems on drug intake, are also part of this technique.
Similarly, healthcare professionals should also be aware of the significance of patient safety to lower the expenses related to preventing injury. Overall, administration and review boards should transition away from a framework of blame, humiliation, and punishment in favor of one focused on awareness and avoidance.
Improvement Plan
Digitizing drug dispensation practices is key to solving the majority of medication errors. IT-based technologies like digital practitioner order entry, computerized dosing closets, bar-coded drug dispensing at the bedside, and computerized medication management are crucial aspects of methods to avert drug dispensing errors. In particular, digital entry of prescriptions by practitioners has been found to reduce medication errors by up to 55-83% (Sutton et al., 2020). Error rates can also decrease by 31 percent and probable side effects by 63 percent after bar-code and computerized dosing closets dispensing are deployed in pharmacies and hospitals (Devin et al., 2020).
Hospitals and pharmacies must encourage the adoption of best practices such as conducting due diligence before making prescription. These may comprise a review of prescribed medications before giving to a patient, analysis of the interaction of different medications, and possible side effects (Riaz et al., 2017). Likewise, vendors should track the expiration date when selling it to the medical facility.
Audience’s Role
The audience can act as influential program ambassadors and may include nurse, legislators, faculty members, students, and others. They can play various roles including the following:
- To help in the program’s development and launch, and to ensure its long-term viability.
- To assist program employees in planning and designing a program, providing advice depending on their expertise, promoting program continuity and viability, and managing the demands of other stakeholders.
- To further enhance the program, ambassadors can identify areas for improvement and give feedback on new activities.
Resources or Activities To Encourage Skill Development
Resources and activities to encourage skill development should primarily entail employee retraining on the use of emerging healthcare technology. The hospital or clinic can conduct regular sessions until all employees are updated. Participants may feel tired and lose focus if the sessions are too long. There needs to be a wide range of technology used in training. Each class should contain a focus group discussion and learning activities.
Conclusion
Medication administration is a common issue causing numerous outcomes. Medical errors significantly increase the cost of treating a patient and increase the duration of hospitalization. Partial information in the medical history of a patient tend to lead to the interruption of previously chosen treatment or therapy. Likewise, the administration of wrong treatment regimens also increasingly tangles the identification of adverse drug responses. Such mistakes should be prevented in order to boost the nation’s health, cut expenses, and improve the healthcare system. The improvement plan consists of consecutive steps to be followed by a medical facility to ensure drug administration safety.
References
Alanazi, A.A., Alomi, Y.A., Almaznai, M.M., Aldwihi, M., Aloraifi, I.A., & Albusalih, F.A. (2019). Pharmacist’s intervention and medication errors prevention at pediatrics, obstetrics and gynecology hospital in East Province, Saudi Arabia. International Journal of Pharmacology and Clinical Sciences, 8(2), 122-128. Web.
Devin, J., Cleary, B. J., & Cullinan, S. (2020). The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis. Systematic reviews, 9(1), 1-17. Web.
Haroutounian, S. (2019). Preventing medication errors at home. Oxford University Press, USA.
Latino, M. A., Latino, R. J., & Latino, K. C. (2019). Root cause analysis: Improving performance for bottom-line results. CRC press.
Mazhar, F., Haider, N., Ahmed Al-Osaimi, Y., Ahmed, R., Akram, S., & Carnovale, C. (2018). Prevention of medication errors at hospital admission: a single-centre experience in elderly admitted to internal medicine. International Journal of Clinical Pharmacy, 40(6), 1601–1613. Web.
Riaz, M. K., Riaz, M., & Latif, A. (2017). Review – Medication errors and strategies for their prevention. Pakistan Journal of Pharmaceutical Sciences, 30(3), 921-928.
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. In StatPearls [Internet]. StatPearls Publishing.
Strom, B., Hennessy, S., & Kimmel, S. (2019). Pharmacoepidemiology. John Wiley & Sons.
Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ digital medicine, 3(1), 1-10. Web.