Prevalence and Prevention of Medication Errors in Australian Healthcare Settings
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This assignment discusses the prevalence of medication errors in Australian healthcare settings, their consequences on patients, healthcare professionals, and facilities. It also evaluates two inter-professional practice central approaches for prevention and strategies to overcome barriers.
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Running head: ASSESSMENT 1: WRITING ESSAY INTER-PROFESSIONAL PRACTICE & PATIENT SAFETY Name of the Student Name of the University Author note
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1ASSESSMENT 1: WRITING ESSAY As the world population is increasing, healthcare is facing more challenges than it used to face before. Increasing amount of patients and their interventions has put tremendous stress on the healthcare professionals and the reason is stress is to provide adequate quality care to each patient within a healthcare facility(Keers et al., 2013). According to the World Health Organization, The definition of medication error states that any controllable event that causes patient harm or inappropriate use of that medication while in control of healthcare professional or the patient. These error occurs due to actions such as wrong, product labeling, prescribing and communicationrelatedfault,packaging,nomenclature,andcompounding,dispensing, administration, distributing and monitoring related mistakes (Osemene & Lamikanra, 2012). The primary aim of this assignment is to point out the prevalence of medicational error within Australian healthcare settings. Further the effect of this adverse condition on the patients, their family and on the healthcare system will be described. After that two inter-professional practice central approach will be critically evaluated so that one of those can be used for prevention of medicational errors. Furthermore, potential barriers while achieving those targets and the strategies to overcome the barriers will be mentioned. To understand the prevalence of medicational error in Australia, the literature review conducted by the Australian Commission on Safety and Quality in Healthcare should be mentioned as it was aimed to understand the medication safety in Australia. According to Roughead, Semple & Rosenfeld (2016), the literature review was conducted within the time frame of 2008 to 2013 and review was conducted on various stages of the patient’s hospital journey and collected data related to Adverse Drug Reaction or ADR or error rate related hospital stay. While statistically analyzing the medication error related hospital admissions, it was observed that the error rate risen from 1.4% to 3% in the chosen timeframe (Keers et al.,
2ASSESSMENT 1: WRITING ESSAY 2013). Further while analyzing the hospital charts related to admission to hospital it was observed that more than 60% people felt that they were suffering from medication error in their previous healthcare settings, while within the current healthcare setting the error rate was 1.25% per patient. On the other hand, the literature review also incorporated rates for prescription relatedmedicationerrorandaccordingtotheresearch,themedicationerrorrelatedto prescription was found to be 5 to 11% (Barton et al., 2012). Whereas, while medication I healthcare facilities, the rate was found to be 9%. Finally, the medication error while discharge was found to be 11%. Therefore, from this above discussion, of medication error in healthcare settings of Australia, it was found that medication error is one of the prevalent adverse condition the patient and the healthcare facilities are facing currently in Australia (Dooley, Wiseman & Gu, 2012). If the rates are calculated statistically, there in 0.5% medication error related event occurs in Australian healthcare settings every day. However, there is a lack of recent literature reviews that can demonstrate the current prevalence rate of medicational error in Australian healthcare facilities. However, if the current challenges of healthcare settings is considered, the rate is supposed to increase in current times (Barton et al., 2012). While describing the consequences of medication error on patients, their family and on the healthcare facility, the situations when such error can occur should be discussed. According to Quélennec et al., (2013), medication error may occur while prescribing or administrating medicine to a patient, further medication error can also be unintentional and such situation may also arise that patient is exposed to a medicine which effects his or her health adversely. Moreover, intentional misuse can also be seen. These medicational errors are preventable and when a patient is harmed by any preventable medical error, a feeling of betrayal and disbelief emerges that affect the wellbeing of the patient (Flynn et al., 2012). Effect of such errors made
3ASSESSMENT 1: WRITING ESSAY by healthcare professionals affect their mental and professional wellbeing as well. They develop feelings such as shame, disgust, guilt and self-doubt and the adverse effect of this mental health condition can be drastic. While conducting a research regarding this issue, Radley et al., (2013) mentioned that nurses and doctors develop suicidal behavior in the maximum incidences after them intentionally or unintentionally commits any mistake while providing care to a fragile patient. Majority of the healthcare experts due to this shame and guilt are unable to inform their patient regarding medicational error they performed and according to Hartnell et al., (2012), only 5% healthcare experts confess their medicational errors in front of the patients. Therefore, they themselves close their chance to reconcile and amend their errors as confessing their errors to the patient could have provided them with mental force and courage to review and change the system that made them commit mistakes that could have been life threatening to the patient. Further, legal issues might also affect the medical profession of the healthcare professionals as the family of the patient is free to file compliant regarding any such medicational error occurred in the healthcare facility. This action might result in revoking the license of the healthcare professional and hence, with a tremendous emotional pressure and stress, the career of the healthcare professionals is affected due to medicational error (Flynn et al., 2012). On the other hand, the healthcare facility or hospital can also face lawsuit as the hospital is also liable for the incident. It can lead to huge settle cost and the reputation of the hospital is put on stake. Further, the hospital might face less productivity as the healthcare professionals making medicational error might not be able to continue their work with the hospital due to guilt and shame (Radley et al., 2013). Furthermore, maximum of the time will be spend on investigation, prevention, identification of the medicational errors. Hence, the hospital will become stagnant and no further improvement will be seen in case of technology, affecting the reputation and re-accreditation of
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4ASSESSMENT 1: WRITING ESSAY the hospital. Hence, medicational error not just affect the patient, and its family, but also the healthcare expert and the healthcare facility as all of them loss their most precious aspect due to medicational error (Hartnell et al., 2012). In the previous sections, the assignment describes different consequences of medicational errors and their types that affect the patient, the healthcare facilities and the professionals dealing with it (Vertino, 2014). Hence, there should be some strategies to deal with these medicational errors within healthcare system. These strategies should enhance the inter-professional practice among the healthcare facilities so that error free practice can be determined. The First strategy should involve the healthcare professional confessing his or her mistake if any medicational error occur and provide a detailed strategy to the healthcare facility that will eliminate the error from his or her practice. According to Toles et al., (2012), this will enhance the transparency in the healthcare system and healthcare facilities will be able to understand the reason and a proper framework through which the error will be eliminated from the practice. However, Johansen (2012) thinks that such confession will be demotivational for the healthcare professional and they might develop suicidal tendencies as accepting the fault weakens the person and destroys the self-confidence. Hence, the healthcare facility should ask the justification in personal conversation with the healthcare professionals. Further, the healthcare experts should arrange a meeting in private with the healthcare facility and discuss the error and the measures that can be used for preventing medicational error. So that a structured framework to deal with such error is present within the system (Toles et al., 2012). The second inter-professional strategy that can be used to deal with medicational error is implementing a no-blame error in the system. If the healthcare facility directly charges a
5ASSESSMENT 1: WRITING ESSAY healthcare expert for the medicational error he or she has made and loudly announces such incident within the system, there is a high probability that the healthcare expert will never confess any medicational error again (Antunes-Alves et al., 2014). Hence, instead of blaming the professional for the error, the facility should focus on implementation of strategies that can help to eliminate that mistake and reinforce a strong and error free system. Researcher also agreed to this strategies and Thoma et al., (2015), determined that it will help to maintain a positive thinking within the thought process of the healthcare facility and he/she will take necessary steps to eliminate the error from his/her process. Unlike each positive strategies, implementation of above-mentioned strategies is also associated with facilitators and barriers that help the facility to implement the safe healthcare medication system within the system (Hosseinzadeh et al., 2012). The primary barrier is associated with the lack of an error reporting system within healthcare systems that leads to spread the medication error related news within the entire system. Therefore, it is the duty of the healthcare facility to develop an error reporting system in the facility so that privacy can be maintained (Hartnell et al., 2012). Secondly, the system lacks a feedback system that would have helped them to understand the extent of their errors and prevent them. Further the healthcare experts do not understand the reporting process and are unable to differentiate between things that can be reported and actions that can be taken to prevent that error (Holmström et al., 2012). Furthermore, fear of lawsuits, fear of blaming process, and documentation of medicational error, lack of ability to recognize medicational error and an anonymous or non-consisted definition of medicational error are some of the barriers that prevent the healthcare exerts to attain high accuracyintheirhealthcarerelatedjob.Thesebarriersaredividedamongindividual,
6ASSESSMENT 1: WRITING ESSAY organizational and patient related aspects hence, cumulative effort will be needed to eliminate all the efforts from the healthcare system (Haw, Stubbs & Dickens, 2014). Interpersonalcommunicationistheprimarywaytoovercomeanybarrierinthe workplace as Makary & Daniel (2016) determines it as the best and most effective way to communicate any problem or concern to the facility. The healthcare facility should enhance or motivate the employees to develop interpersonal communication so that medicational errors can be prevented from the base. The primary reason for medicational error is non-conveyance of important messages from one healthcare facility to another (Mueller et al., 2012). Therefore, the healthcare facilities should implement this strategy to overcome medicational error related barriers. Further, the hospital should develop proper medicational error reporting process and form so that all the personal barriers related to shame, disgust, guilt so that severe errors related to the system can be eliminated. Hence, improving the channel between the higher authorities or managers of the system and the front line healthcare experts will help to remove all the misunderstandings related to process and create a smooth pathway for developing error free process (Kwan et al., 2013). Further, the healthcare facility should implement audit and training related schedules in the system so that any internal fault and defect in the system can be implemented in the process. Further, the healthcare experts should provide with trainings so that stigma, behaviors and attitudes of healthcare experts towards patients can be reduced (Pham et al., 2012). Further, the healthcare facility should implement strategies to reduce the frequency of medicational errors in the healthcare facility so that the accreditation and reliability condition can be improved. Drill situations involving medication error related situation should be included in the practice sessions so that the healthcare experts become aware of the situation and take important steps to deal with it (Graber et al., 2012).
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7ASSESSMENT 1: WRITING ESSAY While concluding the assignment, the adverse condition of medication system related to medication error should be mentioned as it is one of the most prevailing reason for long hospital stays and increased causalities within healthcare system. This is one f the prevailing issues that the healthcare facilities around the world are facing nowadays, Therefore, the assignment mentioned several reasons due to which such incidence are occurring within the healthcare system. Further, the prevalence nature of this error in Australian healthcare system was discussed with reference of authentic literatures. The effect of medication error on patients, their family, the healthcare professionals and the healthcare facility was discussed. Different barriers that prevent the healthcare facility to achieve error free medication system was discussed in the assignment and means or strategies to remove those barriers and achieve excellence was mentioned in the assignment. Hence, finally it should be stated that with proper strategies and conviction, the healthcare facilities should implement strategies so that medicational errors can be minimized in the hospitals.
8ASSESSMENT 1: WRITING ESSAY References Antunes-Alves, S., Thompson, K., Kramer, U., & Drapeau, M. (2014). The relationship between cognitive errors, coping strategies, and clients' experiences in session: An exploratory study.Counselling and Psychotherapy Research, vol.14, issue. 2, pp. 93-101. Retrieved from: https://doi.org/10.1080/14733145.2013.770894 Barton, L., Futtermenger, J., Gaddi, Y., Kang, A., Rivers, J., Spriggs, D., ... & Thomas, J. S. (2012).Simpleprescribingerrorsandallergydocumentationinmedicalhospital admissions in Australia and New Zealand.Clinical Medicine, vol.12,issue 2, pp. 119- 123. DOI: doi: 10.7861/clinmedicine.12-2-119 Dooley, M. J., Wiseman, M., & Gu, G. (2012). Prevalence of error‐prone abbreviations used in medicationprescribingforhospitalisedpatients:multi‐hospitalevaluation.Internal medicinejournal,vol.42,issue3.DOI:https://doi.org/10.1111/j.1445- 5994.2011.02697.x Flynn, L.,Liang,Y.,Dickson, G. L.,Xie,M., &Suh, D. C.(2012). Nurses’ practice environments, error interception practices, and inpatient medication errors.Journal of Nursing Scholarship, vol.44, issue 2, pp.180-186. DOI: https://doi.org/10.1111/j.1547- 5069.2012.01443.x Graber, M. L., Kissam, S., Payne, V. L., Meyer, A. N., Sorensen, A., Lenfestey, N., ... & Singh, H. (2012). Cognitive interventions to reduce diagnostic error: a narrative review.BMJ Qual Saf, bmjqs-2011. DOI:10.1136/bmjqs-2011-000149
9ASSESSMENT 1: WRITING ESSAY Hartnell, N., MacKinnon, N., Sketris, I., & Fleming, M. (2012). Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study.BMJ QualSaf,Vol.21,issue5,pp.361-368.Retrievedfrom: http://qualitysafety.bmj.com/content/21/5/361.info Haw,C.,Stubbs,J.,&Dickens,G.L.(2014).Barrierstothereportingofmedication administration errors and near misses: an interview study of nurses at a psychiatric hospital.Journal of psychiatric and mental health nursing,Vol.21, issue. 9, pp. 797-805. DOI: https://doi.org/10.1111/jpm.12143 Holmström, A. R., Airaksinen, M., Weiss, M., Wuliji, T., Chan, X. H., & Laaksonen, R. (2012). National and Local Medication Error Reporting Systems—A Survey of Practices in 16 Countries.Journalofpatientsafety,Vol.8,issue4,pp.165-176.DOI: 10.1097/PTS.0b013e3182676cf3 Hosseinzadeh, M., Ezate Aghajari, P., & Mahdavi, N. (2012). Reasons of nurses' medication errors and persepectives of nurses on barriers of error reporting.Journal of hayat,vol.18, issue 2, pp. 66-75. Retrieved from: http://hayat.tums.ac.ir/article-1-32-en.html Johansen, M. L. (2012). Keeping the peace: conflict management strategies for nurse managers. NursingManagement,vol.43,issue2,pp.50-54.DOI: 10.1097/01.NUMA.0000410920.90831.96 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
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10ASSESSMENT 1: WRITING ESSAY observational evidence.Annals of Pharmacotherapy, Vol.47, issue 2, pp. 237-256. DOI: https://doi.org/10.1345/aph.1R147 Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.Annals of internal medicine,Vol.158,issue:5_Part_2,pp.397-403.DOI:10.7326/0003-4819-158-5- 201303051-00006 Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US.BMJ: British Medical Journal (Online),pp.353. DOI: 10.1136/bmj.i2139 Muller, S. K., Sponsler, K. C., Kripalani, S., & Schnipper, J. L. (2012). Hospital-based medicationreconciliationpractices:asystematicreview.Archivesofinternal medicine,Vol.172, issue 14, pp. 1057-1069. DOI: 10.1001/archinternmed.2012.2246 Osemene, K. P., & Lamikanra, A. (2012). A study of the prevalence of self-medication practice among university students in Southwestern Nigeria.Tropical Journal of Pharmaceutical Research,Vol.11,issue4,pp.683-689.Retrievedfrom: http://dx.doi.org/10.4314/tjpr.v11i4.21 Pham, J. C., Aswani, M. S., Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P. J. (2012). Reducing medical errors and adverse events.Annual review of medicine,vol.63, pp. 447-463. Retrieved from: https://doi.org/10.1146/annurev-med-061410-121352 Quélennec, B., Beretz, L., Paya, D., Blicklé, J. F., Gourieux, B., Andrès, E., & Michel, B. (2013). Potential clinical impact of medication discrepancies at hospital admission.
11ASSESSMENT 1: WRITING ESSAY Europeanjournalofinternalmedicine,vol.24,issue6,pp.530-535.DOI: https://doi.org/10.1016/j.ejim.2013.02.007 Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems.Journal of the American Medical Informatics Association, vol.20,issue 3, pp. 470-476. DOI: https://doi.org/10.1136/amiajnl-2012-001241 Roughead, E. E., Semple, S. J., & Rosenfeld, E. (2016). The extent of medication errors and adversedrugreactionsthroughoutthepatientjourneyinacutecareinAustralia. International journal of evidence-based healthcare, vol.14, Issue 3, pp. 113-122. DOI: doi: 10.1097/XEB.0000000000000075 Thoma, P., Schmidt, T., Juckel, G., Norra, C., & Suchan, B. (2015). Nice or effective? social problemsolvingstrategiesinpatientswithmajordepressivedisorder.Psychiatry research,vol.22,issue.3,pp.835-842.DOI: https://doi.org/10.1016/j.psychres.2015.05.015 Vertino, K. A. (2014). Effective interpersonal communication: A practical guide to improve your life.The Online Journal of Issues in Nursing, Vol.19, issue 3.pp. 123-178. DOI: 10.1097/OJIN.0000000000000079