Reducing Medication Errors in Acute Care System: Individual and System Issues

NURS2006 SUPPLEMENTARY ASSESSMENT
Clinical Practice Improvement Project Report on
Individual and /or system issues that can reduce or prevent medication errors
by nurses in the acute care system
Student Name, FAN and ID:
Project title;
Individual and /or system issues that can reduce or prevent medication errors by nurses in
the acute care system
Project Aim:
 To identifying individuals and /or system issues that can help in reducing or
preventing medication errors by the nurses in acute care system for a period of 6
months.
 To systematically review and appraise empirical evidence which is associated with
administration medication errors in acute care system.
Background and Evidence that the issue is worth solving:
The major component of health services quality in the field of healthcare provision is the patients’
safety (Hayes et al. 2015). Promoting patients’ safety level starts with identification of medical errors
and what causes them (Stavropoulou, Doherty and Tosey, 2015). Some of medical errors such as
medication errors are the most prevailing errors threatening health which has become a global
problem (Hayes et al. 2015). An important part of the treatment and care process is the execution of
medication and it is also the main part of performance in the nursing profession (Birks et al. 2016).
Understanding the causes of these errors it will be easy to design and implement the most
appropriate intervention to minimise their occurrence.
Relevance of Clinical Governance to your project
The relevance of clinical governance in this report is to promote and raise patient satisfaction,
increase efficiency and collaborative relationship inside and across clinical teams, and raise job
satisfaction level among professionals, and improve clinical outcome (Birks et al. 2016). Clinical
governance will see accountability and continuity of service quality improvement and safeguard high
standards of service through creation of an environment that attract excellence in acute care system
to thrive (Hayes et al. 2015). Clinical governance in this project will involve four pillars which
NURS2006 Supplementary Assessment for Semester Two, 2018. 1

includes:
Clinical performance audit
Clinical assessment enables nurses, doctors, and other professionals in healthcare systems to
measure the quality services they offer (Gibson et al., 2015). It is also useful in helping them to
compare their improvement against a standard to see how they are doing. New proposals also need
further audit to test whether they have been successful.
Professional development and management
To reduce medication errors, knowledge and skills for the nurses that care for patient is important so
that a good job is done. This is why nurses need opportunities to increase their knowledge and skills
(Gibson et al. 2015). This in turn increases job satisfaction among nursing professionals,
management improved performance, and clinicians’ improved credentialing, and improved
professional development training for workforce.
Clinical risk
This would include investigating and minimizing the risks to patients by: identifying what does go
wrong, what can be done to avoid reoccurrence of errors, identifying influences of the errors during
care, and ensuring systems are put in place to prevent or reduce risks.
Consumer values
Improving trust among the patients is vital that nurses work in partnership with patients and their
carers if their goal is to offer quality care. This means, understanding of the priorities and concerns
of the consumers of the services offered by involving them in what you do including planning and
policy making. To gain their views we need to apply patients and carer councils and also monitor
their views through complaints and compliments received through PALS (Gibson et al. 2015). By
doing so there is an opportunity for improved patients outcome, enhanced health service
understanding and responsiveness to consumer need, as well as enhanced consumer and patients’
knowledge and participation in delivery of health services and management.
Key Stakeholders:
The key stakeholders in acute care systems include insurance companies, physicians, government,
pharmaceutical firms, patients and employers. Insurance companies are involved in selling health
coverage plans directly to the patients or through their employer (indirectly) or through government
intersessions (Mitchell et al. 2016). Each stakeholder is involved in one way or the other in reducing
medication errors in this project. Employers also offer health insurance coverage to their employees
deductable from their salaries.
Pharmaceutical firms are involved in the development and marketing of medications prescribed by
doctors for the patients’ treatments (Mitchell et al. 2016). Last and not least the government
NURS2006 Supplementary Assessment for Semester Two, 2018. 2

subsidizes healthcare for the disabled, elderly and the poor. Physicians on the other hand are the
medical care providers while patient becomes the client (Mitchell et al. 2016).
CPI Tool:
The Plan-Do-Study-Act (PDSA) cycle
This model of improvement was developed by Associates in Process Improvement. It is simple,
powerful, and very effective tool for accelerating improvement. However, the tool is not meant to
replace what organizations are using today (Mitchell et al. 2016). Its main goal is improvement
acceleration. Hundreds of health care organisations have successfully used this tool to improve and
accelerate health care processes and outcomes (Birks et al. 2016). This model contains two parts:
One, three important questions, addressed in any order and two, the plan Plan-Do-Study-Act (PDSA)
cycle used to examine changes in the actual work situations (Gibson et al., 2015). The cycle is meant
to guide and determine if there is improvement on change. The following would be the focus.
What are the common medication errors done by the nurses in acute care system? What changes
can be made in those medication errors? What changes that will tell whether the improvement or
success has been achieved?
Team formation
This tool state that, for a successful improvement effort, inclusion of the right people in the
improvement team is critical in the process. No group is equal to the other and in this project teams
will be formed in ways that fits our needs. This is in the stage of planning where best team is
selected from those willing to bring change.
Model of improvement
Setting the goal
This should be measurable and time specific and address specific composition that would be affected
e.g. people or systems (Stavropoulou, Doherty and Tosey, 2015). The specific goal is to identify the
common medication errors in acute care system. This has to be done in small portion of nurses who
NURS2006 Supplementary Assessment for Semester Two, 2018. 3
How we will know change in improvement
What change we can make to result in improvement?
What is to be accomplished?

work in acute care system.
Establishing Measures
To determine if a specific change leads to a certain improvement the teams will use quantitative
measures. There will be determination of per cent which will have reduced from the improved
measures that are suggested.
Selecting changes
Mostly ideas originate from people working within the system or experiences of others who tried
and succeeded.
Testing of the changes
This tool (PDSA) is the shorthand for testing improvement on small scale in the real work setting
through planning, trying, observing, and acting on the learning process (Stavropoulou, Doherty and
Tosey, 2015). This represents the scientific method modified for action-oriented learning. After
determining the changes that can be adopted testing to see whether it worked will be carried out.
Implementing Changes
This is done after a change test on a small scale, learning from each test, and refining the change
through several cycles of PDSA. Thereafter, the team may opt to implement the change on larger
scale e.g. an entire unit (Stavropoulou, Doherty & Tosey, 2015). If changes have been achieved the
implementing changes will have to continue being utilized from then.
Spreading Changes
After successful implementation of a set of changes for an entire unit, the changes can be spread to
other professionals in the organization or organizations. Changes that proved to create the required
change will be shared with other professionals to adapt them so as to reduce the medication errors.
Summary of proposed intervention:
A medication error may be defined as any preventable event that may lead or cause inappropriate
use of medicine or harm to patient (Castaneda et al. 2015). The medication error may occur in any
stage of medication management process including preparation, transcription, prescription, and
administration.
Using information technology to reduce or prevent medication errors
Medication errors are injurious and costly to patients and so common in acute care system.
Reviewed literature states that, particular sets of information technology can minimize the rates of
medication errors occurrences. However, there is inadequate data in existence for different
technologies as those figures available relate to adult settings (Mitchell et al. 2016). Physician High-
tech will significantly minimise the occurrence of severe medication errors among in-patients adults
NURS2006 Supplementary Assessment for Semester Two, 2018. 4