NURS FPX 8030 Assessment 1 Building the Case for Healthcare Improvement

Name

Capella University

NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner

Prof. Name

Date

Understanding Medication Errors: A Critical Patient Safety Concern at Healthy Elite Metropolitan Medical Center

Introduction

Medication errors are an increasingly urgent issue in healthcare settings, emerging as the third leading cause of death in the United States. At Healthy Elite Metropolitan Medical Center, addressing this problem is paramount for improving patient safety and enhancing the quality of care. This article outlines the internal practices that necessitate change, prioritizes addressing medical errors, and develops targeted interventions for quality improvement.

Identifying Internal Practices for Change

Need for Organizational Change

The internal practices at Healthy Elite Metropolitan Medical Center need to be reevaluated to effectively combat medication errors. This includes recognizing factors such as:

Poor Communication: Inadequate communication among healthcare staff often leads to medication errors.
Dosage Mistakes: Administering the incorrect dosage can have severe consequences for patient health.
Negligence: Lapses in attention and care by healthcare professionals contribute significantly to medication errors.
Electronic Medical Record Failures: System failures in electronic medical records can hinder proper medication management.

The Impact of Medication Errors

Statistics on Patient Safety

Research shows that approximately one in every seven patients receiving healthcare services experiences medication errors. Key types of medical errors include:

Technical Errors: Mistakes during the administration of medication.
Delayed Diagnoses: Failure to promptly identify medical conditions.
Inadequate Monitoring: Insufficient oversight following medical procedures.
Test Result Oversight: Neglecting to act on critical laboratory results.

Consequences of Medication Errors

At Healthy Elite Metropolitan Medical Center, medication errors have resulted in significant negative outcomes:

Increased Lawsuits: The organization has incurred over $17.4 million in lawsuits in the past year alone.
Patient Deaths: Tragically, medication errors have led to the deaths of several patients.
Workforce Impact: The organization has experienced layoffs of over 20 healthcare workers due to these errors, exacerbating workforce shortages and negatively affecting healthcare delivery.

Internal Evidence of Medication Errors

Data reveals concerning internal evidence regarding medication errors:

Patient Involvement: In the past 12 months, 40 patients have been directly affected by medication errors.
Readmission Rates: Within just four weeks, 15 patients were readmitted due to medication-related issues.
Patient Deaths: Thirteen deaths occurred within an eight-week timeframe linked to medication errors.

External Evidence of Medication Errors

A Nationwide Concern

Medication errors are not unique to Healthy Elite Metropolitan Medical Center; they pose a widespread threat to patient safety across the United States and globally. Studies by Mulac et al. (2021) and Ferrah et al. (2017) reveal:

High Prevalence: Approximately 19% of healthcare organizations in the U.S. report recurring medication errors.
Common Causes:
- Unauthorized Medication Administration: 4% of errors are due to unauthorized medication.
- Omissions: 43% of medication errors occur due to missed doses.
- Incorrect Dosages: 17% result from administering the wrong dosage.

Organizational Priority for Intervention

Stakeholder Concerns

The impact of medication errors is a significant concern for various stakeholders, including healthcare providers, patients, and the community. The ramifications of these errors extend to:

Physical and Psychological Harm: Patients suffer severe physical injuries and psychological distress as a result of medication errors.
Financial Burden: The financial impact on healthcare providers and organizations is substantial, leading to increased operational costs.
Community Trust Erosion: The prevalence of medication errors can undermine community trust in healthcare institutions.

Quality Improvement Projects for Better Patient Outcomes

Proposed Interventions

To address the critical issue of medication errors, Healthy Elite Metropolitan Medical Center must implement effective quality improvement interventions, including:

Verification Systems: Developing a robust verification system for medication and drug prescriptions to ensure accuracy (Hines et al., 2018).
Barcode Technology: Utilizing barcodes to reduce errors during medication administration.
Awareness Programs: Educating staff and patients about the importance of verifying lookalike medications (Hines et al., 2018).
Error Reporting Systems: Implementing an effective medication error reporting and warning system to facilitate prompt action.
Interdisciplinary Collaboration: Encouraging teamwork among various healthcare disciplines to enhance communication and reduce the risk of errors.

Conclusion

Medication errors remain a critical patient safety issue at Healthy Elite Metropolitan Medical Center. By identifying internal practices that need change, prioritizing the urgency of addressing these errors, and implementing quality improvement interventions, the organization can significantly reduce the incidence of medication errors. As a result, it will enhance patient safety and trust, ultimately leading to better healthcare outcomes.

References

Ferrah, N., Lovell, J. J., & Ibrahim, J. E. (2017). Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents. Journal of the American Geriatrics Society, 65(2), 433-442.
Hines, S., Kynoch, K., & Khalil, H. (2018). Effectiveness of interventions to prevent medication errors: an umbrella systematic review protocol. JBI Evidence Synthesis, 16(2), 291-296.
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer Health.

NURS FPX 8030 Assessment 1 Building the Case for Healthcare Improvement

Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy, 28(e1), e56-e61.
Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business. Australian Prescriber, 41(3), 73.