An in-service program is an executive training and a follow-up discussion of the outcomes with other staff members. It is a crucial instrument for the professionals and beginning staff members in the field of health care and nursing in particular. During the session, the staff members are going to learn the safety improvement plan and their roles in it, analyze the work processes, and get feedback. First, the overview of the implementation plan is presented in relation to the medication administration issue. Second, the staff audiences’ roles are defined to help implementation. Third, the new processes and skills are analyzed through a group activity. Lastly, the audience gives feedback on the plan and session.
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The health care environment rapidly changes, influenced by various technological advances and arising issues, including medication administration. The mistakes need to be carefully analyzed through the case study and evidence-based practices. The problem-based learning (PBL) is considered one of the most innovative strategies for problem-solving and learning in health care (Rakhudu et al., 2016). Improving the current policies and working on developing professional skills through in-service programs application has a range of benefits. All the program’s activities allow the staff to develop a working improvement plan, create a team, and integrate the feedback for future improvement. It sets the standard for nursing practice in patient safety and quality care and increases staff professionalism in providing care with confidence for the reviewed case.
Identifying the existing mistakes is essential in the medical field as the root cause is not always apparent. Various human, environmental, communication, and technical factors can lead to irreversible consequences, including the patient’s death. Examining these mistakes in the specific circumstances allows for creating guidelines for medical institutions and preventing them in the future. An in-depth analysis of the mistake and correlating factors is essential in creating a plan for further actions. The reviewed sentinel case occurred primarily because of human and technical errors combined with environmental and communication factors.
Human error is considered the primary factor contributing to critical incidents in anesthesia between 65-85% of incidents. The causes for it may include fatigue, cognitive limitations, the workload for many others. Thus, the technical training is not enough to prevent the sentinels, but increased understanding of human nature and communication with the team helps (Rakhudu et al., 2016).
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The medical team also did not communicate clear instructions contributing to communication challenges. Communication failures or errors of emission between the medical workers are considered the most common cause of medical failures in about 30% of the cases (Rakhudu et al., 2016). The following failures are divided into information failures in about 60% of the cases and the lack of shared understanding in 40% (Rakhudu et al., 2016). Since communication problems are the most common cause of medical errors, it is imperative to improve the communication channels and means between staff members to minimize information failures and lack of understanding.
The nurses also lacked knowledge or expertise in the field, which led to technical errors. On average, a patient is subject to at least one medical error a day with varying statics among hospitals, considering at least a quarter of them are preventable. To prevent the possible implications from technical and medication errors, the best practice strategies suggest to avoid abbreviation lists, use a computerized entry system to avoid human factor in the possible mistake, and compare patients’ medication orders with other medications through medication reconciliation to avoid omissions, dosing or technical errors and duplications.
The urgency of the event that facilitated the error can be considered an environmental factor. These issues comprise and characterize the current situation as not professional due to the significant risk to the patient’s life. The following factors need to be taken into account and decreased through practice and education.