Introduction
Patient safety is a critical aspect of healthcare delivery, and the prevention of harm is the primary goal of healthcare professionals. Nurses are vital in providing safe patient care and have a professional and ethical responsibility to minimize or prevent safety concerns. Adverse events, unsafe acts, errors, and harm are all examples of patient safety concerns that can occur in healthcare settings. This paper aims to identify a specific patient safety concern, conduct a root cause analysis, and identify strategies that nurses can implement to solve the problem or prevent similar incidents from happening in the future.
Medication Errors in Student Nurses
An example of a practice error encountered by student nurses is the incorrect administration of medication. In one instance, a patient has been prescribed two different medications with similar names, and the nurse administering the medication confused the two drugs (Amaniyan et al., 2020). This error can lead to harm or even death if not recognized and corrected, highlighting the importance of safe medication practices and the need for preventative measures (Mastoras et al., 2019). Despite these risks, implementing effective systems such as double-checking and incorporating inter-professional collaboration to improve communication and education significantly reduces medication errors (Garcia et al., 2019). Therefore, taking proactive measures to prevent errors, such as double checking, educating, and involving more people in the administration process, can help reduce the risk of adverse events.
Consequences
Medication errors notoriously cause adverse events in healthcare settings, with patients often bearing the brunt of these omissions. The problem in this instance was the incorrect administration of medication, which can lead to harm or death if not recognized and corrected (Amaniyan et al., 2020). For instance, if patients are given a high dosage of a medication they are allergic to, it results to severe allergic reaction and hospitalization. This error can have serious patient consequences and underscores the importance of safe medication practices and the need for preventative measures.
Patterns
The incorrect administration of medication is not an isolated event but a pattern of practice error that can occur in healthcare settings. This is reinforced by studies that show that medication errors are one of the most common types of adverse events in healthcare, with reports of such errors accounting for up to 7% of hospital adverse events (Garcia et al., 2019). Additionally, it is reported that most of these errors are preventable and are caused by a lack of understanding of medication-related information, inadequate staff training, and poor communication between healthcare workers (Mastoras et al., 2019). For example, a study in a Canadian emergency department identified several latent threats to patient safety, including poor communication and inadequate knowledge among healthcare workers regarding medication administration (Mastoras et al., 2019). This highlights the importance of preventing medication errors in healthcare settings and the need for effective strategies to mitigate such errors and improve patient safety.
Root Cause Analysis of Medication Errors
Conducting a root cause analysis, it was determined that the cause of the error was a lack of clear communication between the physician and the nurse. This can be exemplified by a study that found that many medication errors happen during medication ordering and administration, which is a process dependent on clear communication between the physician and the nurse (Garcia et al., 2019). Nurses who need more knowledge about medication, its indications, actions, and side effects are at higher risk of administering it incorrectly. Nurses needed more knowledge about the medication and relied on physicians’ verbal orders, which led to medication errors (Mastoras et al., 2019). This highlights the importance of clear communication and adequate knowledge among healthcare workers in preventing medication errors and improving patient safety.
The Importance of Repeatedly Asking “Why”
Asking “why” at least five times until the root cause is reached. The first is why the error happened, the second is why the nurse was administering the medication, the third is why the nurse was not aware of the medications, the fourth is why there was a lack of communication, and the fifth is why the communication was not clear. This technique of asking “why” repeatedly allows us to delve deeper into the cause of the error and identify the root cause. A study by Amaniyan et al. (2020) identified frequent causes of patient safety incidents in emergency departments through a systematic review and found that a lack of communication and insufficient knowledge among healthcare workers were prevalent issues. Another study by Garcia et al. (2019) found that nurses are at high risk of medication errors among healthcare workers due to their heavy workload and lack of time to familiarize themselves with the medications. These findings highlight the importance of identifying the problem’s root cause and addressing it to prevent similar incidents from happening in the future.
Strategies to Reduce Medication Errors in Healthcare
There are ways to decrease medication errors in the healthcare system. These strategies are supported by research demonstrating the importance of effective communication and education in reducing medication errors (Amaniyan et al., 2020; Mastoras et al., 2019). For example, a study by Amaniyan et al. (2020) found that effective communication between healthcare workers and healthcare teams is essential in ensuring medication errors are identified and corrected promptly. Another study by Mastoras et al. (2019) found that education and training programs to improve healthcare workers’ understanding of medication-related information can significantly reduce the risk of medication errors. Furthermore, double-checking systems have significantly reduced medication errors (Garcia et al., 2019). This can be exemplified by a study by Garcia et al. (2019), which found that implementing a double-checking system for medication administration significantly reduced medication errors by up to 50%. The study found that a team of nurses had to implement the system rather than just one person to be effective. This highlights the importance of inter-professional collaboration and teamwork in reducing medication errors and improving patient safety.
Conclusion
In conclusion, patient safety is of the utmost importance in healthcare delivery, and nurses play a crucial role in ensuring that safety concerns are minimized or prevented. The incorrect administration of medication is a standard practice error that can occur in healthcare settings. The root cause of this problem is often a need for more transparent communication between the physician and the nurse, as well as inadequate knowledge on the part of the nurse regarding the medications being administered. To address this issue, nurses can implement various strategies such as improved communication through inter-professional collaboration, education, and training programs to enhance knowledge about medication-related information and double-checking systems to confirm the correctness of medication orders and administration. These strategies have been supported by research and have been found to reduce medication errors and increase patient safety significantly.
References
Amaniyan, S., Faldaas, B. O., Logan, P. A., & Vaismoradi, M. (2020). Learning from patient safety incidents in the emergency department: A systematic review. The Journal of Emergency Medicine, 58(2), 234–244. Web.
Garcia, C., Abreu, L., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicina, 55(9), 553. Web.
Mastoras, G., Poulin, C., Norman, L., Weitzman, B., Pozgay, A., Frank, J. R., & Posner, G. (2019). Stress testing the resuscitation room: Latent threats to patient safety identified during interprofessional in situ simulation in a Canadian academic emergency department. AEM Education and Training, 4(3), 254–261. Web.