Medication errors are considered to be one of the serious adverse events that could take place in a healthcare facility. Medication errors show that the health care organization failed the patient which reduces the trust and satisfaction of the patient. It also causes distress among nurses in cases of accidental medication errors. Every year about 7,000 to 9,000 people lose their lives in the US due to medication errors (Tariq et al., 2022). It has been estimated that $40 billion is spent each year to look after the patient who suffered from medication errors as they then have to have prolonged stay at the hospital. There is a monetary cost as well as some major consequences like physical and psychological pain. Even though it is a serious adverse event but it is not unavoidable, with proper awareness, guidelines, interventions, and policies such adverse events can be prevented by enhancing patient safety quality by a greater range. This paper will be analyzing the elements of a successful quality improvement initiative, factors leading to patient safety risks, identifying the appropriate interventions, and the role of nurses to enhance safety as they are the largest number of healthcare professionals in the facility who work closely with the patients.
The scenario that these analyses are based upon is from the experience of medication error where a 16-year-old boy named Sam who was diagnosed with cancer was admitted to the hospital for Total Parenteral Nutrition (TPN) infusion as he was not able to swallow food due to some problems with the digestive tract. Sam was given an infusion pump at the rate of 190 mL/hrs. but the correct rate is 125 mL/hr. This happened for the first 5 hours of the infusion after which the nurse realized the rate was inappropriate for the patient.
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The intervention that can deal with the factors of safety risks and avoid medication errors should be an electronic-based prescription that makes the reading easier (Roumeliotis et al., 2019). Staff should be trained in medication administration and they should know what the high-risk drugs are so there is more caution. Collaboration and leadership roles should be given for effective communication so the tasks are divided easily and the work burden is reduced.
A quality improvement initiative was taken that consisted of training of nurses and doctors, computer-generated prescriptions, a signature of healthcare personnel, and software-based prescriptions with new designs (Mondal et al., 2022). This initiative significantly reduced medication errors by reducing dosage errors, infusion of drugs rate, time, preparation, and interval. With better guidelines, training of nurses, teamwork, and collaboration, double-checking could have been a mandatory task and Sam would have gotten the accurate infusion pump rate. The electronic health record or printing system would have led the nurse to fill in the details of the treatment being provided to Sam which would have made her realize the mistake with the rate. The manual storage of data causes burnout in the nurses which leads to more errors. Technology would prevent this as everything would be automated.
Quality improvement initiatives are important to reduce medications error because not only do they pose harm to the patients, they impact the cost significantly. When such cases of medication error were reviewed it was found that the mean calculated cost was 1009.58 Euros per case (Kirwan et al., 2022). This shows the significance of the medication error and the loss that an organization has to go through for every individual impacted by medication error.
Another effective evidence-based strategy for ensuring patient safety is the system of barcode medication administration which has proven to decrease errors per 100,000 cases from 0.65 to 0.29. A 55% of decreased was reported in the medication errors (Thompson et al., 2018). Bar code medication administration prevents error as it scans the patient id and the medication packaging before it is administered to make sure it is the right drug. The patient id consists of critical information related to the patient that the bar code system identifies and allows the nurses to be alarmed in case of any error. The cost of operating and implementing this system ranges from about $30,000 to $60,000 which has been concluded by several papers as cost-effective (Naidu & Alicia, 2019).
Improvement initiatives should be taken to avoid any future medication errors so the quality of care being provided to the patients can impr
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