NURS 438 Trends And Issues In Nursing And Health Systems

Medication errors not only cause injury to the patients but prove to be extremely costly to the healthcare system. Although Canada does not have a detailed statistics over medication errors, thorough exploration of the US data suggest that Canada experiences 700 deaths per year due to medication error (Institute of Safe Medication Practices Canada, 2018).  

Background of the topic

Medication error is one of the single most avoidable causes behind the patient harm (Ashcroft et al., 2015). Medicines or the drugs are frequently used by the healthcare professionals as an effective clinical intervention in healthcare. Medication errors mainly occur in any of the three steps of medication use starting from medication prescribing, medicine dispensing and administration of the medicine (Berdot et al., 2012).

Figure: Steps of medication administration

(Source: Karavasiliadou & Athanasakis, 2014)

According to the reports published by Feleke et al. (2015), one of the most common type of medication error arise from medication administration which lead to an increase in the patient mortality and morbidity due to adverse drug reaction. Moreover, medication error causes overall increase in the cost of care and length of hospital stay (Feleke et al., 2015). According to the reports published on CBC news (2013) highlighted that in the hospitals in Ontario, 36 patients suffered from severe adverse affects from medication error and of them 10 are fatal. The main error included that the patients were either the victim of drug overdose in a single go or in a periodic manner. These medication errors jeopardized the health of the patients while increasing they stay in hospital. Apart from the administration errors, other form of medication errors common in Canada is prescribing error (CBC News, 2013).

Thesis statement

Medication errors increases the overall cost of care however, it is preventable via proper application of technology and training of the nursing professionals

Counter argument

As per the reports published by the Cheragi et al. (2013), errors in medication can occur from all the members of the health care system however in nursing profession, medication errors are common. The main reason behind this is, nurses execute a significant number of the medical orders and spend at least 50% of their duty time in the hospital unit, administering medicines to the patients (Cheragi et al., 2013). Sears, O’Brien-Pallas, Stevens and Murphy (2013) is of the opinion that during this 50% of the timeframe, nurses can administer not less than 50 different medications and this statistics increase the risk of committing administration error. A pan Canadian study conducted by Sears, O’Brien-Pallas, Stevens and Murphy (2013) represented that medication error are high in the paediatric unit. In paediatrics, the children are mostly treated as therapeutic orphan as the majority of the formulation are based in adult requirements. This lack of proper prescribing and lack of standardised yet easy-to-use medication delivery system increase chances of medication errors.

Figure: Other factors contributing to medication errors

(Source: Cloete, 2015)

Medication errors have negative impact on the healthcare system and are regarded as an important cause behind the patient’s mortality and morbidity. Although only 10% of the medication errors result in the generation of adverse disease outcomes, these errors have significant negative implications over the patients, their family members and the health care providers. Keers et al. (2013) highlighted that at least 1/5^th of the medication errors occurs in ICU and majority of these are life threatening and increases the overall cost of health care as it warrants the requirement of the costly life sustaining treatments. Moreover, medication errors also cast significant psychological impact on the nursing professionals and thereby reducing their overall confidence. Keers et al. (2013) are of the opinion that the memories of medication error can haunt the health care service providers for years.

In order to reduce medication error, what the nurses can do is to refer to the evidence based practice along with the proper skill training among the new nurses (Cloete, 2015). Numerous international studies have highlighted that the nurses especially the new nurses prefer to seek help from their colleagues for fetching information in order to aid decision making rather than access to evidence-based resources from reliable databases. The reason behind this is lack of time, lack of computational efficiency and low level of confidence. This tendency has reduced the success rate of the previous attempts to decrease the medication errors among the nurses. Moreover, lack of easy access to the policies and proper guidelines of the medication administration results in the generation of poor information fetching habits along which in turn leads to medication error (Cloete, 2015).

Another approach that was used to overcome the medication error is smart infusion pump. This approach was mainly under taken in order to avoid medication error arising from medication administration. In the US, smart infusion pumps is widely used however, it has its share of limitations like errors associated with the intravenous medication administration cannot be successfully eradicated via the use of smart infusion pumps (Ohashi, Dalleur, Dykes & Bates, 2014). Another notable approach for the removal of the medication error in the nursing practice is adoption of computerized provider order entry (CPOE) systems. The systematic review conducted by Ohashi, Dalleur, Dykes and Bates (2014) highlighted that the CPOE system can substantially decrease the frequency of medication errors in the inpatient acute-care settings however, the review lacks clear evidence regarding how it can reduce the overall harm to patients.   

My argument

In my opinion it is not always the negligence from the nursing professionals that causes the medication errors. The high rate of medication errors among the nursing professionals are lack of proper training along with the high workload under clinical settings. The studies undertaken by Duffield et al. (2011) showed that increase in the working hours among the nursing professionals is the main reason behind the error. High workload leads under the medical settings because high job related stress and thereby increasing the chance of medication error. Behind the increase in the workload over the nursing professionals which is causing medication error is high turn-over rate of the nurses and lack of trained nurses under clinical settings. The study conducted by Westbrook et al. (2011) showed that major types of medication errors happen due to the lack of adequate skills and efficiency of the nursing professionals is the root cause behind the medication error. Moreover, there is also some routine violation of the word procedure. Westbrook, Rob, Woods and Parry (2011) is of the opinion that the 70% of all intravenous medications administered to the patients has one or two medication error as the inexperienced nurse fails to review the proper medication history of the patients. They found that this medication administration error can be reduced significantly along with the gain in experience of the nurses (Westbrook, Rob, Woods and Parry (2011).  

As per my opinion, medication errors are controllable under the application of proper technological advancements are proposed in several literatures. However, apart from having benefits, the challenges of such applications are generally high in the present day healthcare setup. In order to access the benefits of the Computerized physician’s order entry (CPOE) system, Ohashi, Dalleur, Dykes and Bates (2014) conducted a systematic review which highlighted that the adoption of CPOE system help in significant reduction in the medication error. In context to this, Georgiou et al. (2013) conducted another systematic review. The analysis of their review highlighted diverse and heterogeneous array of metrics of CPOE which represents different parts of the clinical care process. The in-corporation of the decision support systems with CPOE was associated with increase in the guideline of compliance, increase in the appropriateness of the medication orders along with increase in the rate of vaccination. However, there are certain limitations which are associated with the CPOE. For example, Georgiou et al. (2013) are of the opinion that the information system used by the CPOE showed immense potential to disrupt the work flow of the healthcare professionals and practice across the hospital settings. Moreover the use of CPOE system also showed decrease in the overall clinical work process like workarounds, usability and cost-effectiveness. The reason behind this is CPOE system create an increase in the demand of clerical job. The systematic review conducted by Georgiou et al. (2013) highlighted that the computerised order entry though helped to generate error free results and proper documentation of the medication prescription, the overall process is extremely tedious and cause increase in shifts or tasks of the healthcare professionals especially the nurses. Moreover, CPOE system also demands increase data entry requirements which in turn demands increase in the coverall computerised data entry and increase in the clinicians’ computing skills. This is due to the increase demand of the computing skills, this computerised decision support system are poorly accepted by the health care professionals (Georgiou et al., 2013).  

Another effective approach that are used in order to reduce the chances of the medication administration error include the use of the smart pumps which are popularly known as smart infusion pumps or intelligent infusion devices. These smart pumps are driven via special software known as dose error reduction systems (DERS) and are backed by drug libraries. These drug libraries are regarded as the predominant component of the smart pumps and are used to define parameters like drug type, drug strength, drug dosage, drug administration rate, specific drug dosage limit, intermittent infusions and boluses. This drug library is mainly customised on the basis of hospital requirement or hospital unit wise tailored need. The main function of the smart pumps includes proper clinical advisories and alert indications. Thus keeping the advantages into consideration, it can be said that the smart pump technology for the administration of medication help in the reduction in errors associated to miscalculated doses and oversight (Ohashi et al., 2014). Via ensuring that the prescribed dosing for a particular medication is appropriate to a specific person (in regards to age), the subsequent medication errors arising from fault drug administration or dosage can be potentially reduced. Smart pumps are equipped with soft limits which are simple alerts and can be over-ridden by clinicians and the hard limits cannot be overridden as they are restrictive. The software which drives the functionality of the pump automatically logs data providing proper information in order to guide overall quality improvement and its detection on the medication safety. This automated system which is controlled and co-ordinated by the physicians help in reducing the medication error during the drug administration which may occur as a result of increase in the patient flow or work load (Ohashi et al., 2014). However, the installation of the automated smart pumps also had its share of disadvantages. Ohashi et al. (2014) is of the opinion that the implementation of smart pumps demands overall change in the nursing workflow along with continuous training of the nursing professionals for proper maintenance of the pumps and following the period updates of the software related information of the pumps. The study conducted by Tran, Ciarkowski, Wagner and Stevenson (2012) highlighted that the medication errors are also associated even under the use of smart pump and occurs mainly due to the keypad entry errors (rates and dosage of transcription) or due to generation of faulty transcript of the medication order (misplaced zeros, extra use of zeros and decimal points).

However, implementation of the CPOE systems or other technological advancements in order to control medication error demands effective human resource management. The study conducted by Boswell (2013) highlighted that the implementation of the technological advancements in managing medication errors demands parallel workforce, information technology wing. Thus the human resource management must initiate a new domain in controlling and co-ordinating the IT team with the healthcare professional team.

As per my observation, the implication of the technological advancement in controlling the medication errors will be effective in the long run as. Moreover, it will also help to decrease the overall workload from the nursing professionals. Spaulding and Raghu (2013) highlighted that CPOE and smart pumps usage is guided by evidence based practice and promised effective outcomes. However, empirical findings highlight that 100% effective benefits is not achieved and thus Spaulding and Raghu (2013) recommend increasing relationships of CPOE usage with cost and compliance.  

Recommendations

According to Cheragi et al. (2013), the main effect of the medication errors on the nursing professionals is disturbing. Moreover, it can also be said that managing medication error among the nursing professionals is problematic this is because the majority of the medication errors committed by the nursing professionals remain unreported due to the fear of losing the job or getting penalized. Hence, Cheragi et al. (2013) are of the opinion that the nursing managers are required to demonstrate positive response towards the nursing professionals and thereby reducing their fear and encouraging them to report the encountered cases of the medication error. In doing this the overall patient’s safety can be improved via framing effective measures based on the rate and the type errors. Charles et al. (2014) are of that the CPOE systems though effective in reduces the chances of drug errors, experiences major barriers. Major barriers include cost of implementation, requirement of functioning IT team in order to provide assistance and maintenance to the software from the backend and unwillingness of the healthcare professionals to adopt the new change in the process of care delivery. Khanna and Yen (2014) highlighted that proper funding for standard installation and management of IT team will be helpful ineffective implementation of CPOE system.  In assistance to this, proper change management principle must be implemented in order to increase the level of acceptance of the healthcare professionals towards COPE system. Moreover Shahrokhi, Ebrahimpour and Ghodousi (2013) highlighted that the nurse-related factors are few of the effective factors behind the medication error however, the nursing professionals are integral part of the health-care team and thus their overall performance must be considered under the light of the health-care system. The main parameter will include overall work-force condition, rules and regulations and manufacturing of drugs that might impact the overall performance of the nursing professionals. Thus in order to effectively reduce the chances of medication errors attention over the healthcare system must be done with a holistic approach.  

Conclusion

Thus overall I feel that interventions from the technological approach can be effective in reducing the chances of medication error however, as the literature cited proper training and effective change management principle will encourage the healthcare professionals to spontaneously inherit this technological advancements. In addition to this I think awareness program and incentive structure for the nursing professionals are also required in order to improve their overall dedication in work process. Moreover proper technological assistance will help to reduce the workload over the nursing professionals.

Action plan for nursing professional training

Source: Created by author

References

Ashcroft, D. M., Lewis, P. J., Tully, M. P., Farragher, T. M., Taylor, D., Wass, V., … & Dornan, T. (2015). Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. Drug safety, 38(9), 833-843. https://doi.org/10.1007/s40264-015-0320-x

Berdot, S., Roudot, M., Schramm, C., Katsahian, S., Durieux, P., & Sabatier, B. (2016). Interventions to reduce nurses’ medication administration errors in inpatient settings: a systematic review and meta-analysis. International journal of nursing studies, 53, 342-350. https://doi.org/10.1016/j.ijnurstu.2015.08.012

CBC News. (2013). Medication errors led to severe harm or death in 36 Ontario cases, report finds. Access date: 23^rd July. Retrieved from: https://www.cbc.ca/news/health/medication-errors-led-to-severe-harm-or-death-in-36-ontario-cases-report-finds-1.1305324

Charles, K., Cannon, M., Hall, R., & Coustasse, A. (2014). Can utilizing a computerized provider order entry (CPOE) system prevent hospital medical errors and adverse drug events?. Perspectives in Health Information Management, 11(Fall). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4272436/

Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian journal of nursing and midwifery research, 18(3), 228. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748543/

Cloete, L. (2015). Reducing medication errors in nursing practice. Nursing Standard (2014+), 29(20), 50. Retrieved from: https://www.researchgate.net/profile/Linda_Cloete/publication/270966132_Reducing_medication_errors_in_nursing_practice/links/56ea225e08ae25ede8310132/Reducing-medication-errors-in-nursing-practice.pdf

Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied nursing research, 24(4), 244-255. https://doi.org/10.1016/j.apnr.2009.12.004

Feleke, S. A., Mulatu, M. A., & Yesmaw, Y. S. (2015). Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC nursing, 14(1), 53. https://doi.org/10.1186/s12912-015-0099-1

Georgiou, A., Prgomet, M., Paoloni, R., Creswick, N., Hordern, A., Walter, S., & Westbrook, J. (2013). The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature. Annals of emergency medicine, 61(6), 644-653. https://doi.org/10.1016/j.annemergmed.2013.01.028

Karavasiliadou, S., & Athanasakis, E. (2014). An inside look into the factors contributing to medication errors in the clinical nursing practice. Health Science Journal, 8(1). E-ISSN:1791-809x ?hsj.gr

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Annals of Pharmacotherapy, 47(2), 237-256. https://doi.org/10.1345/aph.1R147

Khanna, R., & Yen, T. (2014). Computerized physician order entry: promise, perils, and experience. The Neurohospitalist, 4(1), 26-33. doi:  10.1177/1941874413495701

Ohashi, K., Dalleur, O., Dykes, P. C., & Bates, D. W. (2014). Benefits and risks of using smart pumps to reduce medication error rates: a systematic review. Drug safety, 37(12), 1011-1020. DOI: https://doi.org/10.1007/s40264-014-0232-1

Sears, K., O’Brien-Pallas, L., Stevens, B., & Murphy, G. T. (2013). The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a Pan Canadian study. Journal of pediatric nursing, 28(4), 351-356. https://doi.org/10.1016/j.pedn.2012.12.003

Shahrokhi, A., Ebrahimpour, F., & Ghodousi, A. (2013). Factors effective on medication errors: A nursing view. Journal of research in pharmacy practice, 2(1), 18. doi:  10.4103/2279-042X.114084

Tran, M., Ciarkowski, S., Wagner, D., & Stevenson, J. G. (2012). A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center. The Joint Commission Journal on Quality and Patient Safety, 38(3), 112-119. https://doi.org/10.1016/S1553-7250(12)38015-X

Westbrook, J. I., Rob, M. I., Woods, A., & Parry, D. (2011). Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf, 20(12), 1027-1034. https://dx.doi.org/10.1136/bmjqs-2011-000089

Boswell, R. A. (2013). Implementing electronic health records: implications for HR professionals. Strategic HR Review, 12(5), 262-268. Retrieved from: https://journals.sagepub.com/doi/abs/10.1345/aph.1R147

Spaulding, T. J., & Raghu, T. S. (2013). Impact of CPOE usage on medication management process costs and quality outcomes. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 50(3), 229-247. https://doi.org/10.1177/0046958013519303