Medical error account for ten percent of all U.S. deaths. Per a study at Johns Hopskins, their patient safety quantified that more than 250,000 deaths per year are due to medical error. This information was published in 2016 in the BMJ, which contradicted the Center for Disease Control’s third leading caused of death being respiratory disease. The team at Johns Hopkins infacticly states that the CDC’s way of gathering national health statistics fail to rank medical errors separately on the death certificate. Advocation by researchers for this update is ongoing. (Daniel, 2016).
One of the most common issues affecting the health care industry are medical errors. These errors have the potential to be non-life threatening, minor, or fatal. These errors are costly to the hospital due to loss suits and it being a cloud of distrust to the patient.
Kaiser Permanente has collaboration with all disciplines (stakeholders) to develop a system for administration of higher risk medications that could be fatal if given in the wrong dosage. This system is called High Alert Medication. It was determined that more than half million doses of HAM were administered, per data collection review process. (Clopp.etal, 2008). Although this process was first rolled out in Northern California’s Kaiser Permanente in 2005, it has since been rolled out as best practice to reduce the errors connected to High Alert Medication within all Kaiser Permanente clinics, hospitals, and at other medical facilities nation wide.
Most facilities nationwide have implemented similar protocols to prevent nursing errors related to medication errors but also unnecessary delays in treatment, incorrect documentation, mistaken identity, under-treatment, preventable falls and infections along with wrong patient wrong surgery (Katuka, 2018). Example, Scheduled left arm amputation, but right arm amputated.
Information Model and Safe Practice
By applying the foundation of nursing model, nursing informatics can help mitigate the risk of errors in healthcare by support in training staff, process improvement and making sure to use best practice guidelines to decrease patient danger and improve the overall quality of care. Everyday, subconsciously nurses utilize technology as a source of data collection in regards to their regular daily workflow. This could also vary depending on the size of the organization. Regardless of the size of the organization, healthcare facility or system, ( For example: University of California.), incorporating the Technology Informatics Guiding Education Reform (TIGER) initiative with informatics would be useful to educate staff on current technological practices and reinforcing that this would improve nursing practice (Calderon & Hedba, 2010).
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The priority of all healthcare organizations is safe practice. The healthcare system for a patient’s is where for most life begins and for others where it ends. The task of safe medication administration revolves around the procedure of Electronic Medication Management (EMM). It begins with the doctors order, the review of those orders by the pharmacist, then verifying any contraindications through the automated system, depending on the form of medication, calculating the dosage right and some medications also require an independent double check by an RN. Before administering the medication, the RN has to perform the 5 rights. Right patient, right time, right dosage, right medication and right route. This is very important in safe practice in regards to medication administration. These steps can also help decrease medication errors. The automated dispensing cabinets, (ADC), and barcode medication administration also play an efficient role in medication management. The closed loop electronic system for medication management can curb human errors if applied correctly. (Pearce & Whyte, 2018)
Making the job of medication administration less intricate through the use of ADC’s and BCMA along with proper training of these devices should reduce possible medication errors. Banding patients with coded wristbands and bedside computers with scanners have also been beneficial in reducing medical errors.
Goal
The goal is to have a decrease in medical error, patient deaths due to medical error and other abnormal patient outcomes due to medical error. Using hospital admission rates from 2013, that was based on a study totaling the hospitalizations of 35,416,200, 25145 deaths were caused by medical error. This translates to 9.5% of all deaths in the USA each year. (Makes, 2016).
Outcomes
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