Name
Chamberlain University
NR-544: Quality & Safety in Healthcare
Prof. Name
Date
This paper explores the evaluation of risks and the significance of patient safety in relation to medication errors. The discussion highlights risk factors contributing to medication errors and strategies to minimize them. Internal and external influences are identified, and the Swiss Cheese Model is used as a framework to illustrate how preventive layers can reduce medication-related mistakes. Additionally, approaches to increase the likelihood of nurses reporting medication errors are discussed. By addressing these issues, healthcare institutions can strengthen safety practices and reduce the frequency of adverse outcomes.
Healthcare is a complex system involving numerous professionals, practices, and responsibilities. Within this intricate environment, the occurrence of errors is almost inevitable. One of the most critical errors is medication-related mistakes. For example, due to inadequate staffing, a nurse may unintentionally administer the wrong drug or provide it to the wrong patient. These errors can have life-threatening consequences, particularly when patients have drug allergies or pre-existing conditions that could be worsened.
Medication errors fall under the domain of risk management and patient safety. They emphasize the importance of recognizing contributing factors, applying safety models, and implementing preventive strategies. The following sections highlight how risks can be assessed, what influences reporting behavior, and how organizational culture affects patient safety.
Ensuring patient safety is a multifaceted challenge. There is no single solution that can completely eliminate medication errors; however, the first step is to understand why such errors occur.
Communication with Providers: When a medication error occurs, it is important to engage in open discussions with the nurse or healthcare provider involved. This helps identify underlying issues and fosters accountability.
Informing Patients: Patients should be informed when an error has taken place. This ensures transparency and allows for assessment of potential consequences, such as adverse reactions (Russell, 2018).
Reducing Interruptions: A critical strategy is minimizing interruptions during medication administration. Research shows that interruptions significantly increase the likelihood of errors. Encouraging a “no interruption zone” during medication passes is an effective preventive measure.
Studies provide insight into how risk management and communication improve patient safety.
Russell (2018): Found that discussions between nurses and risk management teams allow for learning opportunities, reduce the stigma of errors, and encourage reporting.
Beverly et al. (2018): Demonstrated that empowering nurses to openly evaluate mistakes reduces future medication errors. This empowerment builds confidence and enhances peer learning.
Brennan et al. (2016): Reported that nurses are less likely to self-report errors when they fear punishment. A supportive environment and constructive feedback are essential for reporting.
Bungay, Jenkins, & Slemon (2017): Introduced the Safewards model in psychiatric settings, which reduced conflicts and improved overall patient and staff safety. This model promotes collective responsibility for patient care outcomes rather than blaming individuals.
In summary, the literature emphasizes the importance of building trust, offering supportive leadership, and implementing structured safety frameworks.
To understand why nurses may hesitate to report safety or medication issues, both internal and external factors must be analyzed.
| Internal Factors | External Factors |
|---|---|
| Poor communication within nursing teams | Limited support from healthcare system |
| Ineffective risk management practices | Lack of adequate resources |
| Weak nursing leadership | Insufficient training facilities |
| Poor quality control | Inadequate departmental leadership |
Internal factors often stem from organizational culture and leadership styles, whereas external factors are influenced by healthcare policies, resources, and systemic limitations.
The Swiss Cheese Model is a widely recognized framework used to analyze how medication errors occur and how they can be prevented (Chamberlain University College of Nursing, 2021).
Layers of Defense: Each layer of “cheese” represents a barrier against error.
Holes in the Cheese: The holes symbolize weaknesses in these defenses. When holes align, errors pass through and reach the patient.
Application in Practice:
First layer: Prevent errors through staff training and safe medication practices.
Second layer: Investigate incidents and identify systemic weaknesses.
Third layer: Implement maintenance processes to reduce recurrence.
Fourth layer: Introduce new safety measures or strengthen existing defenses.
This model highlights that errors are not solely the fault of individuals but occur due to system-wide failures.
The Quality and Safety Education for Nurses (QSEN) framework emphasizes core competencies that directly apply to medication safety.
Safety: Medication errors can harm patients, put nurses at risk of disciplinary action, and damage the hospital’s reputation. Questions to consider include:
Is the nurse working excessive hours?
Is the unit adequately staffed?
Are medication names too similar, increasing the chance of confusion?
Evidence-Based Practice (EBP): Using research-based evidence helps nurses adopt effective strategies, such as:
Implementing clear identifiers for patients with similar names.
Establishing non-interruption protocols during medication administration.
Advocating for appropriate staffing to reduce workload-related errors.
Medication errors remain a persistent challenge in healthcare. These errors can occur due to internal organizational issues, external systemic limitations, or situational factors such as workload and staffing. Addressing these problems requires supportive leadership, effective communication, and robust risk management systems. Nurses are more likely to report errors when they feel supported rather than punished, leading to collective learning and prevention of future incidents. By applying models such as the Swiss Cheese Model and following QSEN competencies, healthcare systems can strengthen patient safety, improve staff confidence, and reduce overall medication errors.
Beverly, C., Deshpande, J., Green, A., Heo, S., Middaugh, D., & Trevino, P. (2018). Nursing perception of risk in common nursing practice situations: Risk management. Journal of Healthcare Risk Management, 37(3), 19–28. https://doi.org/10.1002/jhrm.21283
Brennan, M., Costello, P., Downes, C., Doyle, L., Higgins, A., Morrissey, J., & Nash, M. (2016). There is more to risk and safety planning than dramatic risks: Mental health nurses’ risk assessment and safety-management practice. International Journal of Mental Health Nursing, 25(2), 159–170. https://doi.org/10.1111/inm.12180
Bungay, V., Jenkins, E., & Slemon, A. (2017). Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nursing Inquiry, 24(4), e12199. https://doi.org/10.1111/nin.12199
Chamberlain University College of Nursing. (2021). NR-544 Week 4: Quality and Safety in Healthcare [Online Lesson]. https://chamberlain.instructure.com/login/canvas
Russell, D. (2018). Disclosure and apology: Nursing and risk management working together. Nursing Management, 49(6), 17–19. https://doi.org/10.1097/01.NUMA.0000533773.14544.e2
