Organizational Performance Initiative
Within the healthcare field, there are numerous organizational issues to choose from. One of the issues is medication error, which occurs far more frequently than people realize and is a common problem in nursing homes and inpatient medical facilities. When a medication error occurs, the facility must investigate to determine why it occurred. Each facility must keep medication errors to a certain percentage. If the nursing home fails to meet these standards, the state inspector will order the facility to develop a corrective action plan.
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To begin with, one of the many challenges that nursing homes and healthcare facilities face is determining how to prevent medication errors. Many medication errors can be avoided if the six rights of medication administration are followed correctly. The six rights are as follows: the right drug, the right dose, the right route, the right time, the right patient, and the right documentation. One of the reasons could be a lack of communication among employees. However, if a patient receives a new medication order or a medication is discontinued, it is not properly documented. Another type of error would be administering the incorrect medication or dose to a patient when a doctor misdiagnoses a patient and prescribes the incorrect type of medication. All of these are examples of medication mistakes.
Working in a group or nursing home, this problem occurs more frequently than most people would like to admit. Twenty-five nursing homes in North Carolina took part in a study to determine the implementation and evaluation of a web-based medication error reporting system (Carey, T. (2007, August). According to the findings of that study, 23 of the 25 nursing homes had a total of 631 medication errors reported. 8% of those errors seriously impacted the patient, requiring monitoring or even hospitalization. 32% were missed doses, 14% were underdosed, and 38.6% were given to the wrong patient, medication, or dose. The study’s findings revealed that the system itself was simple to use and could be useful in the future to reduce the rate of medication error.
Every company will handle medication errors in its own way, according to company policy. Before working in a home, everyone in the group home where I work is trained on the six rights of medications. If three medication errors occur within six months, the staff must retrain the nurse on how to prevent them. If that same employee makes another medication error during those 6 months, their employment may be terminated. However, if you have medication on your record that you believe was not your fault, that staff member can appeal it and explain why. I can give you an example of a medication error that I received and felt was unavoidable, given my working conditions. At the time, the home I worked in had four clients, two of whom were patients receiving round-the-clock care. One was a helper, and one could take care of himself. We were supposed to have double staff in the morning, but the employee who was supposed to arrive at 6 a.m. could not arrive until 8:30 a.m. because she was working at a different house. Normally, this would not have been an issue, but one of the clients had a behavioral issue that morning, which took up most of my time and necessitated the presence of a supervisor. While dealing with that, I completely forgot to give one of the clients their medication that morning, for which I was written up. After further review, they did clear it from my record, recognizing that the likelihood of it happening if I had been properly staffed would have been slim.
Accreditation is the process of giving credit or recognition to something. It demonstrates that an organization can meet all of the requirements of that standard regulation. This is also a method of ensuring that an organization is certified and that the practice is acceptable. Safety standards are guidelines intended to protect products, activities, and processes. There is an organization that works hard to promote these safety standards. A compliance standard is intended to assist an organization in meeting the needs of its customers and stakeholders while also meeting regulatory requirements for that product or service. The quality initiative is a national effort that builds on the work of long-term and post-acute care professionals already in place. Setting specific, measurable goals improves a healthcare facility’s overall quality of care.
Setting things in motion is not always as simple as it appears. Many of these will necessitate a cultural shift in attitude, belief, and behavior. Even after reading Chapter 1 of Healthcare Quality, many physicians encountered the same problems when attempting to change their attitudes, beliefs, and behavior. Ignaz Semmelweis is a prime example of this, as his mortality rate was reduced simply by washing their hands between patients. Despite having the facts in front of them, many physicians refused to change their ways of thinking. It was many years after his death that they realized this was true.
Medication error is not a minor problem because it can be fatal to the patient. Sometimes, a medication error requires no effort from the patient, and simply continuing with the next dose is the best-case scenario. However, in many cases, this can result in serious harm to the patients and even death for many others. In the following paper, we will discuss the problem of medication errors and the solution to prevent future medication errors. Medication errors are classified into four categories. Diagnostic, therapeutic, preventative, and other services. Most of these, however, can be avoided by adhering to the six rights of medication: right medication, right route, right time, right patient, right dose, and right documentation.
As patients, we trust that our doctors can do their jobs properly and that if they say we have cancer or diabetes, it is true. This is what doctors are trained to do to determine the correct diagnosis for patients’ symptoms. However, when a doctor misdiagnoses and the wrong medication is administered. As a result, the nurse can do little because the fault is on the doctor, and the nurse is simply following orders. The rest, on the other hand, can be avoided almost entirely by adhering to the six rights of medication and receiving proper medication administration training. An example of proper medication administration training. I remember working at a group home called Dungarvin. There was one full day of medication training, which was beneficial. Because that company used computers for everything, it was very specific about how new medications were added to the computer system by each client’s name. Not only did they explain it to us, but they also had us practice handing out medication at training. Of course, this wasn’t real medication; we had to use different types of candy or beans to figure out which medication was for the fictitious client on paper. Before we could leave at the end of the day, a nurse tested us on passing out medication, ensuring we used the six rights of medication out loud, and checking it three times to ensure there was no error. When we arrived at the house where we were training, it was the same system, and the concept for passing out medication was also the same. If the clients had any narcotics, we would always do a check-in counter at the start of a new shift to keep track of the medication and ensure no one was stealing the medication. Using the six rights of medication has been extremely beneficial and is a great place to start when it comes to preventing medication errors. However, there is still a long way to go in the health field regarding medication errors.
When attempting to implement a plan, there are numerous factors to consider depending on your position and the area of the health field in which you work, such as hospital, clinic, group home, and so on. The goal remains the same: to reduce or eliminate medication errors. The interdepartmental communication channel in a group home would be the quality assurance and training departments, which would investigate any server case of medication error within a home and implement any changes necessary to reduce the medication error rate.
One of the most important aspects is a solid foundation and clear communication on what must occur when administering medication to patients or clients. Once this is established, the next critical step is to properly document what happened before, during, and after the medication error occurred and to keep files for future reference.
When it comes to data interpretation, it also depends on the company you work for; many hospitals and clinics have switched from paper to computerized documentation. In my group home, everything is still done on paper. A detailed form must be completed if a medication error occurs. Because we are in a group home, we must also contact the client’s caseworker, guardian, and nurse and document that we called, left a message or spoke with them. When medication errors occur, the protocol for this would be retraining the nurse in charge of the home. If the same staff member makes another medication error within 6 months, they will be fired.
I believe that if the first six steps were followed correctly and medications were triple-checked before being given to patients, the medication error rate would be reduced. However, there is another factor to consider that is rarely reported or documented when it comes to medication errors. If a staff member or doctor has been overworked and hasn’t slept in over 24 hours, they may lack the judgment to do their job properly. This is just one example of how medication can occur, and one way to improve that night would be to implement a system in which no staff or doctors work so many hours in a given rotation, which could aid in misdiagnosis. I also believe that companies that have automated documentation will have a better chance of reducing medication errors. My mother was a nurse, and I recall many times when the nurses could not read what the doctor had prescribed for a patient. However, the possibility of mistaking a medication due to penmanship is rare because everything is now documented on a computer. The primary focus should be on preventing medication errors that can result in fatalities. Following the rules and regulations and properly documenting is critical to making this system work.
If medication errors are reduced, healthcare facilities will benefit financially. The standards of the healthcare field change as time passes. As previously stated, medication errors can cause various problems in patients, including health complications and even death. Regarding patients or clients, there have been many issues in the healthcare field, not just medication errors. I’m not sure how this will affect group home business, but they devised an incentive program. This program is known as Pay-For-Performance, and its main goal is to improve quality, efficiency, and overall value in healthcare while rewarding the company or physician. Suppose one of the goals was to reduce medication errors within a group home or healthcare facility to provide better care for their patients. In that case, pay-for-performance can have a significant impact and even provide additional funding to the facilities.
An information management system would be an ideal system to use for data collection and analysis. The current proposal’s goal is to reduce medication errors or eliminate them. I believe that the information management system will contribute to its success because it will help identify the problem and provide a solution to reduce medication errors. In my case, providing training in the six rights of medication and triple-checking the six rights worked. Staff is reducing medication errors due to not paying attention and not rechecking to ensure it is the correct patient or client. Another factor contributing to the success is the pharmacy and how they package the medications. We used bubble packs with one company and pill packs with another, which are medication labeled and dated and placed in a small package with 14 days of medication. I believe that is the best way to increase success and reduce medication errors, particularly in facilities such as nursing homes and group homes where the medication is typically the same. The medication is labeled with the time and date as well as the appearance of the medication. If a pill is missing, the error will fall more on the pharmacy than the staff because it is prepackaged ahead of time.
I believe most healthcare organizations and group homes allow the process because it produces results. Nobody wants to invest in or try a plan that they don’t believe will work or has produced no results. However, this process improves and reduces medication errors among their staff, and as a result, it will be a viable process. Of course, there will be the occasional medication error, but this process will greatly reduce it.
Interdepartmental communication would be crucial, as communication is the key to success in any endeavor. This can be used in various ways, including staff communication and double-checking everything during shift changes. Many medication errors can be detected right at the start of a shift, depending on when it begins. Even having staff double-check another staff member’s medication to ensure it was all given would help improve this. If a staff member is unsure, asking and questioning the results or the process can help.
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Reference
Pierson, S., Hansen, R., Greene, S., Williams, C., Akers, R., Jonsson, M., & Carey, T. (2007, August). Preventing medication errors in long‐term care: results and evaluation of a large scale web‐based error reporting system. Retrieved January 27, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464957/
Philadelphia, T. C. (2014, April 28). Six Rights of Medication Administration. Retrieved January 27, 2018, from http://www.chop.edu/health-resources/six-rights-medication-administration
Medication Errors in Nursing Homes – Standards, Neglect & Statistics. (n.d.). Retrieved January 27, 2018, from http://nursinghomeabuseguide.com/negligence/medication-errors/
(n.d.). Retrieved January 28, 2018, from https://www.achc.org/about-accreditation.html
Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013, March 05). Promoting a Culture of Safety as a Patient Safety Strategy: A Systematic Review. Retrieved January 28, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710092/
Hughes, R. G., & Blegen, M. A. (2011). Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Bethesda, MD: NCBI. Retrieved February 10, 2018.
Agrawal, A. (2009). Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology, 67(6), 681–686. http://doi.org/10.1111/j.1365-2125.2009.03427.x
Wolf ZR, Hughes RG. Error Reporting and Disclosure. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 35. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2652/
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Why would a healthcare organization want to participate in a new healthcare initiative?
Organizational Performance Initiative
Weigh the cost/benefits of a new healthcare initiative of your choice.
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