NURS 4220 – Week 1 Practice Experience Discussion – Identifying a Practice Problem in Need of Improvement

NURS 4220 – Week 1 Practice Experience Discussion – Identifying a Practice Problem in Need of Improvement

In my nursing practice, I have encountered some clinical practice problems that could undermine my patients’ safety, health outcomes, as well as the quality of our healthcare service delivery. My healthcare facility, like all other hospitals, is tasked with the dual responsibility of keeping patients well and safe. These two are inextricably linked, as patient safety concerns often tie directly into patient health concerns such as medication errors, falls, hand hygiene, never events, etc. In my practice setting, one significant clinical practice problem that I would like to see improved is medication errors. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as any preventable event that may result in the wrong medication use or patient harm while the medication is in the control of the healthcare professional or patient (Tariq et al., 2020). Medication errors may be related to prescribing, medication administration, product labeling, packaging, dispensing, distribution, and monitoring to ensure medication is taken correctly.

I chose medication errors because it has become a serious practice problem, not only in my practice setting but all over America. Every hour of every day, healthcare workers are continuously attending to more patients, as well as adapting to the demands of new technology in healthcare, such as electronic health records (EHR) systems. Overwhelming workloads and systemic issues are some of the major causes of medical errors. These occur not only as a result of incompetence or cutting corners on the part of nurses and other healthcare workers but also as a result of faulty systems and working conditions, such as nurses exhausted from working double shifts. Medication errors can result in death, reduced patient satisfaction, and patients’ loss of trust in the healthcare facility. This can be tragic, not only for patients and their families but for the healthcare professionals who are responsible for such errors.

In America today, medication errors have become a serious health burden. According to Shepherd (2018), medication errors are the third-leading cause of death after heart disease and cancer. A recent Johns Hopkins study claims that more than 250,000 deaths in America yearly are attributed to medication errors. This large figure exceeds the Centers for Disease Control and Prevention’s (CDC’s) third leading cause of death — respiratory disease, which kills close to 150,000 people per year (Daniel, 2016).

NURS 4220 – Week 1 Practice Experience Discussion – Identifying a Practice Problem in Need of Improvement

One significant experience I encountered in my healthcare facility was when a patient unknowingly received insulin shots instead of an influenza vaccine. The mix-up occurred when a nurse inadvertently administered Humalog U-100 insulin instead of the influenza vaccine. After a while, the patient began complaining of sweating, weakness and lightheadedness, which later resulted in acute hypoglycemia. After a thorough investigation, it was discovered that the influenza vaccine vial was kept in the nurse’s office refrigerator along with a 10 mL vial of Humaog U-100 insulin. The nurse who administered the shots unknowingly mixed them up because they were not stored in separate, labeled containers.

I had discussed extensively with my unit manager concerning the prevalence of medication errors and will like to be nominated as part of the team which will address this problem in our healthcare facility. She attested to the fact that medication errors have become a high priority in the agenda of our hospital management. She also welcomed my input and suggestions on how to successfully tackle this problem while promising to recommend me to be part of the hospital’s team, which will be inaugurated to address the prevalence of medication errors. After our discussion, her concerns and my strong desire to reduce or eradicate medication errors in my practice setting impacted my decision to address this clinical practice problem.

References

Daniel, M. (2016). Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S.https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_ errors_now_third_leading_cause_of_death_in_the_us

Sipherd, R. (2018). The Third-Leading Cause Of Death In Us Most Doctors Don’t Want You To Know About. https://www.cnbc.com/2018/02/22/medical-errors-third-leading- cause-of-death-in-america.html

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2020). Medication Dispensing Errors And Prevention. In StatPearls. StatPearls Publishing.

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NURS 4220 – Week 1 Practice Experience Discussion – Identifying a Practice Problem in Need of Improvement

In this week’s discussion, you shared your experiences with healthcare practice problems as a consumer and/or as a practitioner. Now, consider your current practice setting and think about something specific and relevant to your practice setting that you would like to see improved or changed. Interview a key leader in your practice setting who can confirm that your practice problem is needed for enhancing delivery or performance in the field. It is important to remember from the beginning that your practice problem must be measurable, and although this comes up more specifically in week 2, it is important to consider this from the start.