This article discusses the importance of medication safety and reducing medical errors in promoting clinical excellence. It analyzes a patient's narrative on medication safety and the consequences of medical errors. The role of clinical governance in ensuring patient safety is also explored.
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Running Head: MEDICATION SAFETY & MEDICAL ERROR MEDICATION SAFETY & MEDICAL ERROR
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MEDICATION SAFETY & MEDICAL ERROR Introduction In order to promote clinical excellence, it is impertinent that medical errors are reduced and medication safety is administered (Choo, Hutchinson & Bucknall, 2010). In the current scope of discussion a patient's mother narrative has been analyzed related to the safety of health care. The video is seen on YouTube and was produced for labor-management patient safety project on medication safety (cirSEIU, 2012). The patient story was related to an actual breakdown in care resulting in the death of Lewis, a healthy 15-year-old boy. Patient Story The narrative was described by the patient’s mother. She recalls the horrifying experience of what happened to her son at the hospital. Her son Lewis was a healthy 15-year-old boy, who played soccer, was a top student in Columbia, SC metro area and he also acted in the community theater. Back at home he was easy-going, very popular amongst his peers, and had a very good sense of humor. He was taken to the hospital after a cosmetic condition and he was slightly dehydrated at that time. After the surgery, he was not producing urine, though his parents reported regarding the same, there was no doctor visiting him (Gaal, Verstappen & Wensing, 2011). He failed to urinate after the surgery and it took him two days prior to changing orders amongst the staffs to increase his fluids to provide adequate dosage. He continued to be in pain after the surgery and was not able to urinate. Lewis weighed 120 pounds and was provided with an adult dosage of NSAID ketorolac tromethamine to reduce his pain. At this juncture, Lewis is seen to be given inappropriate drug without considering for patient safety. His narcotics levels are continuously 2
MEDICATION SAFETY & MEDICAL ERROR increased as he maintains high levels of pain. This was considered to be very dangerous as he was faced with high fluid deficiency. After three days of the surgery, Lewis complains regarding severe, unremitting epigastric pain and no attention was paid to him. The nurses, residents along with other staffs did not act when Lewis showed increasing signs of instability. Lewis is seen to have dark circles under his eyes and he is unable to walk . He starts feeling tremendously weak and is still left unattended by staffs. He feels agonizing pain and has cold sweats. His belly seems to be distended and he has no bowel sounds. His respiratory rate is very high and is still not attended. His parents continually request for the attending physician but no one comes to their rescue. Even at this stage, Lewis is not attended over two days period. Lewis is unable to sustain his condition and dies. His autopsy reports revealed a giant duodenal ulcer. It was with 2.8 liters of gastric and blood secretions in the peritoneal cavity, it was consistent with an NSAID overdose. The primary contributing factor of Lewis decline was identified to be unfamiliarity with reaction and dosing of the drug and medical contradictions with side effects. Further, there were no nurses adequately trained, who could challenge the incorrect orders, change the plans and intervene on a patient (Patel & Balkrishnan, 2010). The physicians, as well as the nurses, failed to assess, intervene and escalate even in case of the alarming condition. They could not identify signs of sepsis and shock with Lewis deteriorating condition. They never called a code in it was necessary. The nurses lacked awareness of the situation, failed to communicate, or escalate and finally rescue the boy from his condition. Analysis of care & contextual factors inpatient 3
MEDICATION SAFETY & MEDICAL ERROR Safety in dealing with a patient is based on process and experience. TheSignificant Event Audit (SEA) offers the most comprehensive process for evaluating a patient’s condition (McKay, Bradley, Lough & Bowie, 2009).Evaluating the patient's case using the SEA, a qualitative evaluation can be constructed. The seven stages of SEA includes; Awareness and prioritization of the significant eventis the first step. In this case, the nurses nor the clinical staffs made the patient's case a priority through the patient condition was deteriorating significantly. The staffs and nurses should have prioritized the case and taken an urgent decision for the patient. Information gathering.Members need to gather information relevant to the case, to identify and prioritize the significant eventin a confident manner (Bowie et al, 2016). The nurse’s neither did other clinical staff was able to diagnose the urgency of the patient's severity. The nurses did not prioritize the event an treated the patient at par with general patients even in his deteriorating condition. The facilitated team-based meetingas few people has access to data and information. Practicing a computer-based system for logging significant cases, which is available to staff and conducting team-based meeting (Gillam & Siriwardena, 2013). There was no mention of computer records for the case or any case being mentioned in the video. This implies that the patient case was not adequately provided and nurses were not aware of the patient's health condition. 4
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Problem Wrong Medicine UsedWrong Medicine Dosage Used Absence of fluid monitoring Negligence of nurses, physicians & healthcare staffsAbsence of physician monitoringLack of integrating parents feedback MEDICATION SAFETY & MEDICAL ERROR Figure1: Fishbone Diagram Analysis of the significant event. It is necessary that the significant event is diagnosed and then analysed on actual potential consequences for quality patient care (Scott, 2009). It can be said that the patient’s case deteriorated as the nurses and physicians failed to act when needed to. None of the staffs or nurses identified the consequences or provide adequate care to the patient. Agree, implement and monitor changeOver-representation of heavily clinical material for audit alienating non-clinical staffs and ignoring flexibility. In this case, it was integral that different team combinations are made on the nature of the event. Reporting failure regarding the team has to be identified as well. The changes agreed by the various nurses and clinical staffs needs to be implemented and then the changes be monitored. Write it upis an integral stage for implementing change process. Other clinical and healthcare staffs did not contribute to the patient case. There was complete ignorance of the patient safety and administration of appropriate dosage which could improvise his health 5
MEDICATION SAFETY & MEDICAL ERROR conditions. A report will serve as a written document for other patient care in the future at the healthcare center. Report, share and review, once the report has been prepared, it needs to be shared and reviewed (Menon & Williams, 2010). The sharing and review of the new process would enable others in the healthcare center to implement better patient care in the future. The report will be shared amongst various stakeholders of the organisation. Clinical Governance Role Clinical governance plays a distinct role to support safe and effective along with person- centered care for patients. Its concepts remain embedded in primary care and pursue excellence for healthcare organizations(Boluarte, 2009). Clinical governance encompasses a set of systems and procedures for improvisation of patient care. Application of clinical governance, especially nursing leadership can create a differential impact on nursing care. In the above discussed patient care, nursing leadership would have enabled nurses to take on more proactive roles such that theyassumegreaterresponsibilityforpatientcases.Nurseswouldhavetakengreater accountability for their practice. As in the above case, none of the nurses took responsibility and failed to identify the problems faced by the patient, such case would not have arisen (Travaglia, Debono, Spigelman & Braithwaite, 2011). Nurses would have to integrate audit and follow prescribed indications willing to maintain high standards in quality care. Reflecting on practice through self-criticism and constructive learning from mistakes is a basic framework for clinical governance effective application. Nurses and other staffs needs to work across interfaces such that they are able to overcome traditional boundaries in health and social care. 6
MEDICATION SAFETY & MEDICAL ERROR The core aim of clinical governance is an enhancement of patient satisfaction, with the application of such aims safety and care of the patient can be brought about in focus (Smith, Latter & Blenkinsopp, 2014). Clinical governance application also enables to learn from others, with a willingness to look outside one’s practice. Nurse for the above patient could have assumed greater responsibility in consulting other nurses or staffs, who have prior experience in patient safety. This would have supported the development of not only learning networks but could have possibly saved the life of the boy. The specific areas for clinical governance includes leadership skills, communication and talent to influence people. Some other factors include effective communication systems amongst primary and secondary care, access to clinical information and a multi-professional approach with management support. It is also required that users are involved in catering to clinical governance (Dückers et al, 2009). As in the above case, it is seen that the parents of the patient were not paid any attention to, this is against clinical governance. In accordance with clinical governance, it is required to focus on partnering with patients for their greater participation and sensitivity to user needs. Moreover, the evidence-based practice could have been accommodated, which was totally absent in the case (Coombes, Stowasser, Reid & Mitchell, 2009). Clinical governance encompasses a set of systems and procedures for improvisation of patient care. It can be said that the application of clinical governance could have allowed more patient-related outcome and adherence to the safe procedure for the patient. Conclusion To conclude, it can be said that medication safety has gained tremendous importance in the recent time period. Nurses and other clinical staffs need to be aware of various medications 7
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MEDICATION SAFETY & MEDICAL ERROR along with their side effects. While administering any sort of pain-related drugs especially there has to be conducted a comprehensive analysis undertaken by nurses so as to prevent medical errors and patient's suffering. 8
MEDICATION SAFETY & MEDICAL ERROR References Boluarte, T. A. (2009). The emotional impact of medical error involvement on physicians: a call forleadershipandorganizationalaccountability.Swissmedicalweekly,139(0102). Retrievedfrom https://smw.ch/resource/jf/journal/file/view/article/smw/en/smw.2009.12417/ d4e7a3ae1b1683fbd4734fe7c3acc6a30831cf61/smw.2009.12417.pdf/ Bowie, P., McNaughton, E., Bruce, D., Holly, D., Forrest, E., Macleod, M., Kennedy, S., Power, A., Toppin, D., Black, I. and Pooley, J. (2016). Enhancing the effectiveness of significant event analysis: exploring the personal impact and applying systems thinking in primary care.The Journal of continuing education in the health professions,36(3), 195.doi: 10.1097/CEH.000000000000098.Retrievedfrom https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063067/ Choo, J., Hutchinson, A., & Bucknall, T. (2010). Nurses' role in medication safety.Journal of nursing management,18(7), 853-861. doi: 10.1111/j.1365-2834.2010.01164.x.Retrieved fromhttps://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2834.2010.01164.x cirSEIU.[Sep6,2012].MedicationSafety:APatient’sStory.Retrievedfrom <https://youtu.be/CspIrlJ2bd4> Coombes, I. D., Stowasser, D. A., Reid, C., & Mitchell, C. A. (2009). Impact of a standard medicationchartonprescribingerrors:abefore-and-afteraudit.BMJQuality& Safety,18(6),478-485.doi:10.1136/qshc.2007.025296.Retrievedfrom https://qualitysafety.bmj.com/content/18/6/478.short 9
MEDICATION SAFETY & MEDICAL ERROR Dückers, M., Faber, M., Cruijsberg, J., Grol, R., Schoonhoven, L., & Wensing, M. (2009). Safety andriskmanagementinterventionsinhospitals.Medicalcareresearchand review,66(6_suppl),90S-119S.doi:10.1177/1077558709345870.Retrievedfrom https://journals.sagepub.com/doi/abs/10.1177/1077558709345870 Gaal, S., Verstappen, W., & Wensing, M. (2011). What do primary care physicians and researchers consider the most important patient safety improvement strategies?.BMC health services research,11(1), 102.doi: 10.1186/1472-6963-11-102. Retrieved from https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-11-102 Gillam, S., & Siriwardena, A. N. (2013). Frameworks for improvement: clinical audit, the plan- do-study-act cycle and significant event audit.Quality in Primary Care,21(2). McKay, J., Bradley, N., Lough, M., & Bowie, P. (2009). A review of significant events analyzed in general practice: implications for the quality and safety of patient care.BMC family practice,10(1),61.doi:10.1186/1471-2296-10-61.Retrievedfrom https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-10-61 Menon, K., & Williams, D. D. (2010). Investor reaction to going concern audit reports.The Accounting Review,85(6), 2075-2105.doi: 10.2308/accr.2010.85.6.2075. Retrieved from https://www.aaajournals.org/doi/abs/10.2308/accr.2010.85.6.2075 Patel, I., & Balkrishnan, R. (2010). Medicationerror managementaround the globe: an overview.Indian journal of pharmaceutical sciences,72(5), 539. doi: 10.4103/0250- 474X.78518.Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116296/ 10
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MEDICATION SAFETY & MEDICAL ERROR Scott, I. (2009). What are the most effective strategies for improving quality and safety of health care?.Internalmedicinejournal,39(6),389-400.doi:10.1111/j.1445- 5994.2008.01798.x.Retrievedfrom https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-5994.2008.01798.x Smith, A., Latter, S., & Blenkinsopp, A. (2014). Safety and quality of nurse independent prescribing:anationalstudyofexperiencesofeducation,continuingprofessional development clinical governance.Journal of advanced nursing,70(11), 2506-2517.doi: 10.1111/jan.12392.Retrievedfrom https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12392 Travaglia, J. F., Debono, D., Spigelman, A. D., & Braithwaite, J. (2011). Clinical governance: a reviewofkeyconceptsintheliterature.ClinicalGovernance:AnInternational Journal,16(1),62-77.doi:10.1108/1477727111114592.Retrievedfrom https://www.emeraldinsight.com/doi/abs/10.1108/14777271111104592 11