Systems-Level Safety Concern in a Healthcare Setting Using SBAR Format
Situation (S)
Medication administration is a critical yet high-risk responsibility in nursing across all healthcare environments. Errors during medication administration represent a significant safety concern at the systems level because they have the potential to affect many patients simultaneously and cause serious harm or even death. Common errors include administering the wrong medication, incorrect dosages, improper timing, or giving high-risk medications without necessary prior assessments such as lab tests or vital sign checks. Additionally, adverse drug reactions or allergic responses following medication administration further compromise patient safety. To prevent these errors, healthcare settings must prioritize patient safety through rigorous infection control measures, clear interdisciplinary communication, and strict adherence to safe medication practices.
Background (B)
Medication errors are frequent in healthcare and have profound human and financial consequences. In the United States alone, these errors contribute to approximately 7,000 to 9,000 deaths annually, with many more patients experiencing adverse drug reactions that often go unreported (Tariq et al., 2023). Errors can occur at various stages of medication management, including prescribing, transcription, dispensing, and administration. Factors contributing to errors include healthcare providers’ insufficient knowledge of drugs, illegible prescriptions, and failure to check for allergies. Nurses may confuse medications with similar names, administer incorrect dosages due to dispensing errors, or fail to use barcode scanning technology to verify medications. The introduction of electronic barcode scanning has demonstrated a significant reduction in medication errors.
National patient safety guidelines, such as those from The Joint Commission (2021), emphasize strict protocols to enhance medication safety. These protocols include verifying patient identity using two identifiers (e.g., name and date of birth) prior to medication administration and requiring a second nurse’s confirmation for high-risk or pediatric medications. Safe medication administration also involves verifying the correct medication, dose, timing, route, and documentation. Immediate labeling of medications prepared in syringes or IV bags and accurate documentation of IV lines are essential to prevent errors.
Assessment (A)
Medication errors have far-reaching consequences impacting patients, healthcare staff, and organizations. The table below summarizes these effects:
| Stakeholder | Impact Description |
|---|---|
| Patient | Physical harm or health deterioration, loss of trust in healthcare providers, adverse reactions |
| Staff (Nurses) | Disciplinary measures such as license suspension, emotional distress, potential legal actions |
| Organization | Significant financial costs (in billions annually), reputational damage, and safety investigations |
Beyond physical harm, medication errors can erode patient confidence in healthcare systems, leading to reluctance to seek future care. Nurses involved in errors often experience guilt, stress, and fear of disciplinary action. Organizations face substantial financial burdens and reputational risks (Tariq et al., 2023). Therefore, ensuring thorough checks of allergies, contraindications, and drug interactions is critical to preserving patient trust and maintaining the quality of care delivered.
Recommendation (R)
To address medication errors effectively, healthcare systems are encouraged to implement electronic medication management systems (EMMS). These systems automate essential tasks such as dosage calculations, infusion rates, timing, and medication verification, resulting in improved patient outcomes and cost savings (Westbrook et al., 2020). Evidence from controlled before-and-after studies indicates that EMMS implementation can reduce serious medication errors by as much as 50%.
This recommendation aligns with principles of High-Reliability Organizations (HROs), which focus on achieving zero harm by fostering a culture of safety and continuous process improvement. A key characteristic of HROs is their proactive stance on failure prevention—identifying risks before they result in adverse events and refining procedures accordingly. EMMS supports these principles by enabling early detection of errors and facilitating ongoing monitoring for quality enhancement.
Potential Barriers and Solutions
| Barrier | Description | Intervention |
|---|---|---|
| Financial Costs | Initial and maintenance costs (~$285,000 per hospital over 15 years) | Phased implementation beginning with high-risk departments to distribute expenses |
| Staff Training | Need for comprehensive education and transition from paper to digital systems | Scheduled training sessions outside clinical hours to build competence and reduce resistance |
Importance of Shared Decision-Making
Successful EMMS deployment requires collaboration among healthcare providers, IT experts, pharmacists, and patients. Physicians and nurses provide insights on usability and clinical workflow integration, while patient feedback ensures the system supports a positive care experience. This inclusive approach fosters shared ownership, which is crucial for sustainable improvements in safety and quality.
Measuring Outcomes
A quality improvement team should be established to track medication error rates across departments, assessing changes before and after EMMS implementation. Key performance indicators include the total reduction in errors, decrease in severe incidents, and long-term financial savings due to fewer adverse drug events.
Current Care Delivery Model and Impact of Recommendation
Healthcare settings utilize varying care delivery models. For example, acute care settings often use functional nursing with task-based delegation, while inpatient wards may adopt team nursing involving registered nurses (RNs), licensed practical nurses (LPNs), and aides. Regardless of the model, EMMS enhances medication safety by streamlining administration, enabling cross-checks of patients and medications, and alerting clinicians to contraindications or allergies. This technology is especially valuable for nurses who work across multiple units or with unfamiliar patients, significantly reducing the risk of medication errors and improving overall care quality.
Summary Table of SBAR Analysis
| SBAR Component | Content |
|---|---|
| Situation (S) | Medication administration errors present a critical safety risk impacting multiple patients across healthcare settings. |
| Background (B) | Thousands of deaths annually linked to errors at various medication stages; national standards require patient ID verification and safe practices. |
| Assessment (A) | Errors cause patient harm, staff consequences, and organizational financial and reputational damage; patient trust is compromised. |
| Recommendation (R) | Implementation of EMMS to reduce medication errors, supported by HRO principles; phased rollout and training advised to address barriers; stakeholder collaboration essential. |
References
Tariq, R. A., Vashisht, R., Sinha, A., et al. (2023). Medication Dispensing Errors and Prevention. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/
The Joint Commission. (2021). 2021 Hospital National Patient Safety Goals. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/simplified-2021-hap-npsg-goals-final-11420.pdf
Westbrook, J. I., Sunderland, N. S., Woods, A., Raban, M. Z., Gates, P., & Li, L. (2020). Changes in medication administration error rates associated with the introduction of Electronic Medication Systems in hospitals: A multisite controlled before and after study. BMJ Health & Care Informatics, 27(3). https://doi.org/10.1136/bmjhci-2020-100170
Westbrook, J. I., Gospodarevskaya, E., Li, L., Richardson, K. L., Roffe, D., Heywood, M., Day, R. O., & Graves, N. (2017). Cost-effectiveness analysis of a hospital electronic medication management system. Journal of the American Medical Informatics Association, 22(4), 784–793. https://doi.org/10.1093/jamia/ocu014