Clinical Issue – Medication Errors
In modern healthcare, nursing professionals have to deal with one of the most constant dangers – medication errors. With the existence of hospitals, long-term care facilities, and community health centres, medication errors have become one of the major threats to patient safety and efficient delivery of care services (Rodziewicz et al., 2023). These mistakes can result in overdose, adverse effects, higher health expenditures, and patients’ lack of trust in the healthcare system. Despite all the endeavours that have been made to solve the problem, medication errors do occur at alarming rates, which serves as a reminder for a holistic and sustainable strategy on this important clinical issue.
The significance of medication errors is not limited to single patient outcomes but it represents the core obligation of healthcare providers to provide the best care and patient safety within acceptable limits. As first-line practitioners, nurses are the backbone of the medication administration process. In this capacity, nurses are very effective in detecting and stopping medication errors before they reach the patient. In addition, medication error prevalence puts into focus systemic problems in healthcare delivery, like, ineffective communication among healthcare teammates, lack of standardized protocols, and difficulty in getting access to the right medication information (Rodziewicz et al., 2023). Consequently, the medication error eradication form is multifaceted and involves clinical skills, inter-professional collaboration, and continuous quality improvement. A national and international lens helps deepen the understanding of the issue and design specific measures to improve medication safety practices and treatment maximization.
Discussion of the Issue from a National or Global Perspective
When evaluating the national/global view of medication errors, it becomes obvious that this issue is more than just a domestic issue and that it affects all healthcare systems on a global scale. The WHO states that medication errors are a serious cause of morbidity and mortality, and over 2 million deaths are attributed to preventable medication-related incidents annually (World Health Organization, 2019). These mistakes overburden an already strained healthcare system and erode public faith. Regarding medication errors in high-income countries with advanced healthcare systems and low-resource settings with limited access to basic medications, the global community must be unanimous in addressing the problem. By looking at the variation of medication error rates, root causes, and contributing factors in different regions globally, stakeholders are able to identify best practices and strategies for global-scale medication safety improvement.
Healthcare delivery and patient outcomes are affected in numerous complicated ways by medication errors. Apart from jeopardizing patient safety, medication mistakes cause additional expenditures on healthcare expenses, extended hospital stays, and avoidable adverse happenings. Patients who are victims of medication errors often have health conditions worsened, treatment delay, or permanent harm leading to long-term health, emotional, and financial impact (Tsegaye et al., 2020). Also, healthcare professionals are legally and ethically accountable when prescription errors happen, thus signifying the need for 100% strategies for prevention and cutback. The spread of medication errors not only impacts individual patients but also affects healthcare organizations, payer systems, and public health efforts, consequently underlining the importance of handling this issue in terms of the healthcare delivery scheme.
Currently, healthcare organizations are using several methods and undertakings to reduce the frequency of medication errors and medication safety. These strategies frequently incorporate technology-based approaches like electronic health records (EHRs) and barcode medication administration systems as well as human factor systems intervention such as medication reconciliation processes and interdisciplinary team training as indicated by Mulac, (2021). Beyond that, the usage of evidence-based guidelines, medication management protocols, and quality improvement programs is an essential part of the standardization of medication practices and the reduction of the risks of making mistakes. Undeniably, the current efforts have not been enough to address the prevailing issues associated with implementing and sustaining medication safety measures in various healthcare settings. Hence, continuous research, innovation, and collaboration are necessary to realize high medication safety standards and guarantee superior patient care.
Importance of the Issue to Healthcare and Nursing Profession
The role of detecting medication errors in healthcare, which is of paramount importance in achieving superior quality of patient care and safety, should not be disregarded. Medication errors may be the cause of adverse drug events and treatment complications and, at times, may lead to the death of the patient (Tariq et al., 2024). Firstly, medication safety is the basis for high patient care standards and harm reduction. Ensuring patients receive the right medication in the right dosage at the right time is a critical task for frontline nurses. Leaving this matter unattended undermines the quality of nursing care and breaks the trust between the healthcare providers and their patients. Secondly, medication errors may contribute to a lack of confidence in healthcare systems and prevent people from seeking medical help immediately and appropriately.
The significance of medication errors to the establishment of nursing practice standards and guidelines reaffirms the profession’s emphasis on evidence-based care and a perpetual quality improvement process. The standards of nursing practice, including those set by professional bodies such as the American Nurses Association (ANA), emphasize that medication safety protocols and risk reduction strategies ought to be prioritized (American Nurses Association, 2020). Nurses must comply with the rules and regulations in a manner suitable for safe medication dispensing and minimal or no error chances. Without integrating medication safety principles into nursing practice, nurses can face ethical quandaries, unprofessional behaviour, and possible legal reprisals. Besides that, not attending to such errors reinforces the system’s inefficiencies and excludes the chance for innovation and development of practice. The consequences of ignoring medication errors go way beyond the single patient; they deeply affect healthcare quality, efficiency, and sustainability.
Role of the DNP-Prepared Nurse
The DNP-prepared nurse is a key figure in identifying, resolving, and preventing medication errors and other deficiencies in care practices that improve patient safety and the quality of care, as argued by Reynolds & Sabol (2023). DNPs, as a result of their education, hold a unique position in aiding in diagnosing the systemic factors leading to medication mistakes and subsequently developing solution-driven, evidence-based interventions. Among their primary activities is evaluating processes in place, and using them to identify those deficiencies or inefficiencies. Critical analysis of clinical workflows, medication administration protocols, and interdisciplinary communication processes by DNPs may discover the roots of medication errors and as a result, they are able to design targeted strategies beforehand. Furthermore, DNPs can assess the impact of implemented interventions through systematic outcome evaluation and improvement methodologies, ensuring iterative improvements in medication safety.
In addition to this, DNP-prepared nurses are already filled with vast knowledge and experience that they need to come up with new and effective ways to prevent similar issues. By utilizing the knowledge of pharmacology, pharmacokinetics, and pharmacodynamics, DNPs will be able to make medication management practices more favourable and readily minimize the chance of adverse drug events (Reynolds & Sabol, 2023). Furthermore, these competencies of the DNPs in evidence-based practice and leadership empower them to lead medication safety improvements at the organizational level, ultimately leading to systemic change and bringing a culture of continuous improvement. Another important part of the DNP-prepared nurses’ duty is working with the interdisciplinary team and stakeholders to reduce medication errors. Through synergy with physicians, pharmacists, allied health professionals, and health administrators, DNPs may ensure multidisciplinary approaches to medication safety, relying on the knowledge of different stakeholders to devise individualized solutions that address the specific requirements of patients and healthcare institutions.
Application of the PDSA Framework
The PDSA framework is based on the plan-do-study-act principle, enabling a logical and sequential improvisation process for resolving quality problems, e.g., medication errors (Knudsen et al., 2019). In the Plan phase, healthcare teams develop their objectives, set measurable goals, and generate strategies for improvement. The likely scenario is that the organization will perform a root cause analysis to identify contributing factors to medication errors, e.g., communication breakdowns, inadequate training, or inefficiency in the workflow. Through the participation of the main stakeholders such as frontline nurses, pharmacists, doctors, and administrators, teams can make sure that the implementation process is collaborative and comprehensive.
During the ‘Do’ stage the teams implement the developed interventions in a small-scale pilot or trial setting. This will allow providers to observe the impacts of the interventions in such an environment and make necessary modifications before completing the scale-up. For instance, using BCMA technology in a single unit or department allows nurses to examine the system’s functionality, determine how convenient it is to use, and identify issues during the adoption process. The collection and analysis of data is done by the teams during the Study phase to assess the results obtained from the interventions in medication safety (Knudsen et al., 2019). It might entail tracking the medication error rates, monitoring the adherence to new protocols, and getting feedback from frontline staff members. Based on the research carried out in the study phase, teams move to the Act phase and fine-tune or innovate on the interventions to ensure success before scaling up the initiatives across the organization. It is worth noting that if BCMA implementation leads to a high level of reduction of medication errors in the pilot unit, healthcare leaders may decide to expand this technology system-wide and go hand in hand with complete staff training and continuous support.
Conclusion
This paper raises an alarming issue of medication errors in an international context and their impact on patient safety and healthcare system performance. The necessity of doing something about this clinical problem is imminent considering the influence of its impact on patient care quality, the nursing practice standards, and the whole healthcare system. Medication errors jeopardize patient safety and healthcare outcomes which elaborate on the need to implement strategies that address these issues thoroughly. Consequently, DNP-prepared nurses are challenged to utilize all the knowledge, abilities, and leadership skills they have gained to be part of the solutions. Through the implementation of quality improvement activities, interprofessional collaboration, and evidence-based practice, the DNP-prepared nurse can be a catalyst for change and increase the safety of medications, which in the end can result in better patient outcomes and a stronger nursing care profession.
References
American Nurses Association. (2020). Nursing scope of practice. American Nurses Association. https://www.nursingworld.org/practice-policy/scope-of-practice/
Knudsen, S. V., Laursen, H. V. B., Johnsen, S. P., Bartels, P. D., Ehlers, L. H., & Mainz, J. (2019). Can Quality Improvement Improve the Quality of Care? a Systematic Review of Reported Effects and Methodological Rigor in plan-do-study-act Projects. BMC Health Services Research, 19(1), 1–10. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4482-6
Mulac, A. (2021). Barcode medication administration technology used in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223
Reynolds, S. S., & Sabol, V. (2023). The Role of Doctor of Nursing Practice-Prepared Nurses to Improve Quality of Patient Care. Creative Nursing, 29(2), 172–176. https://doi.org/10.1177/10784535231195425
Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2023, May 2). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2024). Medication Dispensing Errors and Prevention. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30085607/#:~:text=With%20the%20number%20of%20substances
Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication Administration Errors and Associated Factors Among Nurses. International Journal of General Medicine, 13(13), 1621–1632. https://doi.org/10.2147/ijgm.s289452
World Health Organization. (2019). Medication Without Harm. World Health Organization. https://www.who.int/initiatives/medication-without-harm
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Question 
For this assignment, you will select a current clinical issue in nursing or healthcare that creates a gap in practice. You will write a scholarly paper that includes the following content:
A discussion of the issue from a national or global perspective.
Clinical Issue – Medication Errors
Why this issue is important to healthcare and the nursing profession.
What is the DNP-prepared nurse’s role in identifying a solution to the issue/gap in practice?
Using the PDSA framework, describe how each part of the framework can be applied to a potential solution for the gap in practice you identified.