Community College of Baltimore County USA
Fundamental of Nursing NUR 101
PICOT: EVIDENCE-BASED NURSING PRACTICE
Present a PICOT based project to explain, analyze and recommend modern plans to reduce medication errors in HealthCare Facilities.
Running Head: EVIDENCE-BASED NURSING PRACTICE 1
PICOT: EVIDENCE-BASED NURSING PRACTICE
Modern Plans to Reduce Medication Errors in HealthCare Facilities
CLINICAL ISSUES AND PICOT IMPLEMENTATION
Abstract and Background
According to the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is "defined as an unintentional failure in the drug treatment process that causes or has the potential to cause harm to the patient. Prescription, dispensing, storage, preparation, and administration errors are the most common preventable cause of unwanted adverse events in medication practice, posing a significant public health burden.”
Medication errors can happen anywhere in the medication-use system. For example, when prescribing a drug, entering information into a medical history system, preparing or
dispensing the drug, or administering the drug to a patient. Failure to communicate drug orders, illegible handwriting, incorrect drug selection from a drop-down menu, confusion over similarly named drugs, confusion over similar packaging between products, or errors involving dosing units or weight are the most common causes of errors. Medication errors can be caused by human error, but they are more often caused by a flawed system with insufficient backup to detect mistakes. Although medication errors can be serious, they are not common and are often insignificant. However, it is critical to detect them because system failures that result in minor errors can lead to serious errors later on. By allowing healthcare professionals to electronically send prescriptions to pharmacies, electronic prescribing can help reduce prescription errors. Medical alerts, clinical flags, and reminders are other ways that technology can assist in reducing medication errors and improving patient safety. Also, the effective way to reduce medication errors is to create an electronic reporting system and then make changes to prevent similar mistakes from happening again. Even a close call should be reported. Employees should be reported.
An intervention called computerized physician order entry (CPOE) enables healthcare
professionals to enter orders electronically. With regard to lowering pharmaceutical errors, this method has probably had the biggest impact of any automated intervention; in one study, the incidence of major errors dropped by 55% and the rate of all errors by 83%. In order to structure all orders with dosage, route, and frequency, ordering is computerized; which are readable and the order can always be identified, this promotes safety in various ways. Also, adequate information are provided throughout the process. Lastly, all orders can be checked for a number of concerns such allergies, treatment alternatives, excessive doses, and drug-laboratory issues.
Although there are few data from health care, bar coding of drugs appears to be useful for reducing error rates. The main impediment to implementation has been the inability of drug
manufacturers to agree on a common approach; this should be legislated. Outside of medicine, bar coding is widely used; it reduces error rates to about a sixth of those caused by keyboard entry and is less stressful for workers. Bar coding can quickly ensure that the drug in question is the intended one, and it can also be used to track who is giving and receiving it, as well as different time intervals.
The opposite of computerized medication prescriptions would be using a handwritten system. With a handwritten system there is more room for error because of illegible handwriting. The NIH states that a “study evaluating over 9,000 prescriptions written by 78 primary care providers in New York and Massachusetts found that illegibility errors occurred on average more than once per prescription – an alarmingly high rate.” It is also time consuming trying to figure out what the prescriptions says and keeping track of handwritten medications lists for each patient. Also, for the physicians to get the list to the pharmacy and then to the nurse wastes time because, it would not information that is readily available right away. This decreases the safety and efficiency of the quality of care of the patient. Computerized medication prescriptions is computer-to-computer transmission of information. The information can be placed in by the doctor as soon as he/she has decided what medication they need from the pharmacy and for the nurse to administer. The pharmacy can quickly verify what medication information is needed and the nurse can view the order once it is available and ready to administer. It also minimizes room for error because of fewer illegible prescriptions, better ability to track medications, and decreased need of medication clarification. This also decreases patient’s wait time to get medication. There are still medication errors that can happen with e-prescriptions, but overall it is more efficient, modern, and safer for the patient. It also makes work a little easier for healthcare personnel.
Implementation of desired outcomes can happen right away. If healthcare facilities follow correct protocols, and procedural steps, and make sure to enforce them, changes can be seen immediately. Medication error management involves many people within the health care facility being on the same page and taking numerous steps to accomplish the goal. It begans with the physician documenting the correct prescription needed for the patient. The pharmacy must be able to fill the correct prescription. Lastly, it involves the nurse using the correct drug, dosage, time, route, patient, and input correct documentation. The nurse should also verify for allergies and make sure to check medication expiration date. Each of these steps should be happening with each and every patient at every visit or encounter. Every time there is a need for medication administration the nurse must make sure to take the correct steps and follow right protocols to promote an overall safe environment for the patient.
A medication error is defined as an unintended failure in the drug treatment process that harms the patient or has the potential to do so by the National Coordinating Council for Medication Error Reporting and Prevention. The most frequent preventable causes of unintended adverse events in the use of medications include prescription, dispensing, storage, preparation, and administration errors, which place a major burden on public health.