Introduction
One of the primary concerns in healthcare regarding patient safety is the mistakes made by nurses. The most common mistake of nurses is the incorrect administration of medicines: it is administered too quickly, the nurse introduces the wrong medicine, the wrong concentration, or not promptly. These errors can be regarded as committed through negligence, which, with an unfavorable outcome, may entail criminal punishment. In addition, many nurses made mistakes during anesthesia and intensive care, which could cause several dangerous complications and lead to death. Nursing mistakes can be prevented by eliminating their leading causes: psychological stress, physical overload, inattention, or negligence.
Addressing the Issue
Evidence-Based Practice (EBP)
The issue of information loss during shift transfers is a significant concern worldwide. As the practice demonstrates, very few hospitals can claim to have explicit policies in place regarding the sharing of information between nurses taking shifts and one another (Kuo et al., 2020). Many nurses claim that a significant problem is illegible handwriting in the appointment list, as well as the inarticulacy of information on numerous labels (Kuo et al., 2020).
There is evidence that a well-readable label should have a matte surface to prevent glare from disrupting visual perception (Kuo et al., 2020). In this case, the letters must have a height of at least 2.5 mm (Alrabadi et al., 2021). Less than half of medication labels adhere to these standards (Kuo et al., 2020). Packaging design is also essential: it is absolutely unacceptable that packages of different drugs have the same design. It is hazardous if the appearance of the package does not distinguish the same drug, but in different dosages.
Research
Research provides various examples of how mistakes occur in nursing practice. For example, an eleven-month-old child was vaccinated against hepatitis B, and the nurse injected the drug intramuscularly. However, the instructions for the vaccine state that children under one year old or weighing less than 10 kg should not receive the drug; it can only be injected into the anterior surface of the thigh (Pouya et al., 2019). In another example, although the maximum volume of the drug for intramuscular administration should not exceed 10 ml for an average adult, the nurse ignored this rule (Kuo et al., 2020). These errors illustrate some of the variations in how incorrect administration of the drug can occur.
Process Improvement (PI)
In the process of distributing medicines, nurses very often had to answer numerous questions from colleagues and doctors, which distracted them and drew their attention. To prevent errors, a program has been developed that includes a standard for the distribution of medicines. This standard includes items such as preparing medicines in a designated quiet area and wearing a belt that signals to colleagues not to ask questions or distract (Kuo et al., 2020).
As a result of applying this standard, the number of drug errors has decreased by more than half (Holmes et al., 2020). Additional precautions are also necessary when working with medicines in similar packages and with similar labeling. Ultimately, changing labels by pharmaceutical companies can eliminate the problem; at the same time, barcoding, confirmation of the correct dose, course, time, as well as confirmation that the medicine was given to the patient to whom it was prescribed, can essentially prevent such errors (Kuo et al., 2020). Thus, by understanding the most common mistakes in nursing activities, effective ways to prevent them can be identified.
PI Process Application
I would apply the PI process to ensure that nurses comply with drug safety requirements. After receiving the list of medical appointments, they need to check the appointments with the attending physician. As part of the check, nurses should discuss all appointments, ask questions, and make sure that everything is clear to them (Holmes et al., 2020). During use, nurses should check the label on the package when retrieving it from the medicine cabinet. They also need to double-check the label on the ampoule before typing the drug into the syringe.
Before administration, it is essential to verify the dosage of the drug as indicated in the prescription sheet (Kuo et al., 2020). Medicines in similar packages must be stored on different shelves. I have chosen this method because the root cause of nurses’ mistakes is a lack of concentration. It can be caused by various external factors, such as physical or psychological fatigue, or self-confidence(Holmes et al., 2020). The presence of a precise algorithm of actions worked out to automatism will be a universal solution in this case.
Data Sources
Outcome Data
Outcome data will be obtained from various medical institutions. Nurses will undergo anonymous interviews in which they will be asked whether they and their colleagues have made mistakes. At the same time, an anonymous survey will include spaces for a detailed description of cases with examples. Additionally, nurses rate their level of benefit from using the method on a 10-point scale (Holmes et al., 2020). They will describe whether any errors occurred after using it, and if so, which ones.
Process Data
Process data sources will, like outcome data sources, include anonymous interviews with nurses from various medical institutions. Information will be collected on how successfully the changes are being implemented and whether any adjustments are needed. Evidence-based practice will also be applied (Kuo et al., 2020). Memos from various textbooks and medical manuals will be taken to compile a precise and easy-to-remember algorithm of actions. Research will also be used to collect data on errors and joyous moments in the course of solving the problem of medical errors.
Capturing & Disseminating Data
Among the methods most often used for capturing the results of the survey, such as calculating indicators of descriptive statistics, ranking and scaling, identifying correlation dependence between individual features, and graphical processing of information, will be employed. As one of the methods of interpretation, we can single out the method of factor analysis, which allows us to search for the hidden structure of relationships among a variety of variables, significantly reduce their volume, and identify factors that influence respondents’ responses. The fact that this technique is used in numerous data capture and processing systems is another benefit (Pouya et al., 2019). An essential role in capturing the results of the survey will also be played by methods and interpretation algorithms that give meaning to the survey results.
The data will be disseminated through scientific publications. By publishing both online and offline publications, it will be possible to popularize an algorithm that prevents medical errors. Furthermore, educational activities might be used to distribute data (Pouya et al., 2019). By conducting seminars, master classes, and training sessions for nurses, it will be possible to popularize the data obtained as a result of the study. Such disseminated data will contribute to their further dissemination in the long term as a result of nurses’ use in daily practice.
Organizational Culture Considerations
Professional competence and management are the primary focuses of successful medical personnel in firms where task culture is prevalent. Therefore, in this type of organization, implementing the received data will be the easiest (Kuo et al., 2020). In organizations characterized by a power-based organizational culture, a natural relationship exists between indicators of career development level and career orientation (Alrabadi et al., 2021). This is the consistency in the workplace, combined with the desire to build rapport with superiors and the notion of a competitive personality as someone who can establish relationships with anyone. In such organizations, it is necessary, first of all, to influence the authorities so that they prioritize compliance with the algorithm of patient treatment.
Conclusion
Thus, a nurse must continually study and receive thorough theoretical training. Of particular importance is the specific psychological preparation of the nurse for the upcoming treatment of the patient, including the development of the ability to concentrate on studying a particular patient. Therefore, not only is the amount of knowledge needed, but also the systematization of theoretical knowledge with the help of diagnostic theory, for example, an algorithm based on evidence-based practice. This can become a more reliable protection against medical errors. Regardless of the causes, medical errors occur due to loss of concentration. A universal way to prevent errors is to use a precise algorithm that helps ensure all the rules for administering the drug to the patient have been followed.
References
Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-Rabadi, D., Farha, R. A., AlRabadi, S., & Kraut, R. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78-86.
Holmes, T., Vifladt, A., & Ballangrud, R. (2020). A qualitative study of how inter professional teamwork influences perioperative nursing. Nursing Open, 7(1), 571-580.
Kuo, S. Y., Wu, J. C., Chen, H. W., Chen, C. J., & Hu, S. H. (2020). Comparison of the effects of simulation training and problem-based scenarios on the improvement of graduating nursing students to speak up about medication errors: A quasi-experimental study. Nurse Education Today, 14(12), 954-964.
Pouya, A. B., Mosavianasl, Z., & Moradi-Asl, E. (2019). Analyzing nurses’ responsibilities in the neonatal intensive care unit using SHERPA and SPAR-H techniques. Shiraz E-Medical Journal, 20(6), e81880.