Service Improvement Project: Student Guidance

This report highlights the prevalence of medication error in the UK and the need to implement an improvement project for addressing the issue. It also elaborates on the application of Lewin’s change management theory in the healthcare setting for implementing bar-coded medication administration.

Running head: REPORT
Service Improvement Project: Student Guidance
Name of the Student
Name of the University
Author Note

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Executive summary
Medication errors have been identified as the most prevalent health-threatening errors that are
performed at healthcare settings. Adverse health events caused due to medication errors
create negative impact on patient health outcomes, thus increasing the mortality rate, length
of hospitalisation, and associated healthcare costs. Though it is unquestionably difficult to
remove all incidents of medication errors, reducing their rates is fundamental to
ensuringpatient health and safety.This report highlighted on the prevalence of medication
error in the UK and the need to implement an improvement project for addressing the issue.
The report also elaborated on the application of Lewin’s change management theory in the
healthcare setting for implementing bar-coded medication administration.

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Table of Contents
Introduction................................................................................................................................3
Literature Review.......................................................................................................................4
Research Question......................................................................................................................5
Search Strategy...........................................................................................................................5
Summary of findings..................................................................................................................6
Implementation Strategy..........................................................................................................10
Application of the theory.....................................................................................................11
Evaluating change management...........................................................................................12
Resistance to change management.......................................................................................13
References................................................................................................................................14
Appendix 1:..............................................................................................................................18

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Introduction
Improvements in medical therapeutics have occasioned chief developments in the
delivery of healthcare services for patients who have been diagnosed with one or more
diseases, nonetheless these advantages have also been supplemented by augmentedhealth
risks. A medication error commonly refers to a fault such as, omission or commission at any
stage along the path that usually arises when a physician prescribes a particularmedicine
(Rose et al., 2017). The pathway usually ends when the patient trulyobtains the medication.
Medication errors have been found to give rise to adverse drug events (ADE) that are defined
as injuryor damage to a patient, owing to the exposure to particular drug. Time and again it
has been established that medicinal product refers to a substance that is anticipated to be
administered to, or consumed by a person, with the aim of effectively preventing or managing
a disease (Nanji et al., 2016). In other words, medication error can be defined as an avoidable
event that might lead to or cause inappropriate use of medication and patient harm, while the
prescribed medicine is under the control of the healthcare provider, consumer or patient.
There are a plethora ofdiverse approaches that are typically followed for the classification of
medication errors. One method is to base the cataloguing in the order of medicine use
procedure, such as, prescription, transcription, provision, administration or observing.
Another method is to contemplate the kinds of errors happening, such as,incorrect
medication, frequency, dose, route of administration and wrong patient.
Time and again it has been established that some of the most common factors that are
associated with medication errors in hospital are absence of necessary therapeutic training
amid healthcare professionals, inadequate patient knowledge, inadequate drug knowledge,
poor communication, emotional and physical health issues, fatigued healthcare staff, and lack
of adequate perception of the associated risks (World Health Organization, 2016). The
primary reason for selecting this topic of investigation can be accredited to the ‘Monitoring

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and Reducing Medication Errors in Hospitals National Conference 2019’that will highlight
on the need of lowering medication errors and the resultant damage and harm caused to
patients in hospitals. It was highlighted in the brochure of the conference that an estimated
237 million cases of medication error occur every year in England (Healthcare Conferences
UK, 2019). In addition, it also elaborated on the need of preventing these errors with the
accurate implementation of training, technology and standardised procedures.
Furthermore, recent reports from England also state that medication errors lead to as
much as 700 deaths everyyear and can also be cited as a significant factor between 1,700-
22,300 other ones. The report helped in identifying the fact that roughly 1.15 billion
medication prescriptions are prepared each year. In addition, it also highlighted a case study
where a woman, aged 92 years, who had been residing in a care home had been administered
incorrect medications for numerous weeks, following a mix-up of her prescription with
another patient that resulted in eye irritation (Triggle, 2018). The aforementioned findings
provided an insight into the fact that medication error was not just restricted to a particular
healthcare setting, but was a global issue and can create dreadful levels of injury and death
that are completelyavertible. This report will present a literature review on medication error
interventions and will elaborate on an improvement project for bringing about a change.
Literature Review
According to a research reports published by the NHS, it has been stated that a total of
237 million medication errors occur within the province of England and other parts of the
United Kingdom (Addelman, 2019). Further, research studies also reveal that approximately
100 deaths can be prevented every year that occur on account of adverse drug reactions. In
this context, it is worth noting that researchers from the prestigious universities of Sheffield
and York have reported epidemiological findings that suggest approximately 712 deaths can
be avoided that occur as a result of adverse drug reactions (Ashcroft et al., 2015). On an

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average, 1700 to 22,303 deaths take place annually due to medication errors. Medication
errors results in increased economic expenditure around £ 98.5 million on yearly basis and
attribute to poor care outcome for the patients (Baqir et al., 2015). Research studies further
suggest that the rate of medication error is most common within emergency care unit
followed by primary care unit and long term care unit (Elliot et al., 2018; Baqir et al., 2015).
Medication error is expected to cause poor health outcome, increase associated healthcare
cost and prolong hospital stay which can cumulatively diminish the quality of life of the
patients (Ashcroft et al., 2015). In order to effectively address the problem related to
medication error and poor health outcome, an exhaustive search would be conducted on the
electronic databases in order to retrieve relevant research articles that can help to identify the
evidence based strategies to prevent medication error and related adverse drug reactions.
Research Question
On the basis of the background research, the following research can be articulated:
What are the effective evidence based interventions that can be adapted within a clinical
setting to prevent medication error and related adverse drug reactions?
Search Strategy
A rigorous search was conducted on the electronic databases of Google Scholar and
PubMed using appropriate search terms in order to obtain research journals that were aligned
to the research question. Grey literatures which are basically academic materials that are
published by organizations apart from commercial or academic purpose were not considered
for this research study. In addition to this, appropriate exclusion and inclusion criteria were
used in order to obtain relevant research papers. The inclusion criteria comprised of
characteristics such as consideration of research papers that were published between 2015 to
2019. In addition to this, papers that were published in English language were considered and

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research journals that were accessible for complete text were only considered. On the other
hand, the exclusion criteria typically comprised of papers that were published in foreign
languages other than English. In addition to this, papers that were not accessible for full text
and papers that were published before 2015 were considered. Also, BOOLEAN operators
such as OR/AND were used in combination with the search terms to obtain relevant results.
The following search terms were used to conduct a search across the electronic databases:
Medication error, adverse drug reaction, poor patient outcome, prevention, interventions,
positive care, improved patient outcome, quality and reduced hospitalizations
The search terms were used in combination with the BOOLEAN OPERATORS such as
Medication error OR adverse drug reaction AND Prevention. The use of the BOOLEAN
terms helped to obtain the most appropriate research papers that were aligned to the concept
of the research question.
Upon using the search terms on the electronic databases, a total of 10 papers were
retrieved. Additionally 2 more papers were identified from the Cochrane library databases.
However, 5 papers were eliminated as it did not meet exclusion/inclusion criteria and lastly 7
papers were considered for the literature review. (Refer Appendix 1)
Summary of findings
Goedecke et al. (2016), stated that medication error is most likely to lead to an
adverse drug reaction or an unintentional drug failure which can lead to compromised patient
safety. The researchers were of the opinion that reducing risks related to medication error
could help to promote positive patient outcome. In this context, the researchers stated that the
process of reducing medication error and promoting increased safety was a shared
responsibility that operated between the care professionals and the patients. The overall
findings of the researchers suggested that integration of improved pharmacovigilance

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standards and medication safety standards can help to acquire improved patient outcome.
Further, the researchers also suggested that the improved compliance with the EU regulatory
network can help to assure improved patient safety.
Rodziewicz and Hipskind (2019), also stated that medication error has emerged to be
a serious problem that compromises the overall public health and safety. The researchers are
of the opinion that medication errors are basically of two types which include, errors related
to omission which emerge as a result of not taking an action. On the other hand, the second
category of errors arise as a result of taking incorrect actions. The example for the first kind
of error can be cited as overlooking a particular dose of medication administration. On the
other hand, the second category of errors would include administering incorrect medication
via the wrong route or preparation of incorrect dose. Rodziewicz and Hipskind (2019)
mentioned that care professionals are often subjected to a wide range of negative
psychological effects such as stress, burnout or anxiety owing to the strenuous nature of the
clinical environment. Further, excessive patient load and chaos within the care unit can serve
as distraction and lead to medication errors. Fostering a constructive work environment free
from stress and the fear of shame and guilt can help to promote positive patient outcome.
Further, improved knowledge about the type of medication errors and adherence with the
medication safety standards can help to ensure increased patient safety.
Charkhat et al. (2015), stated that medication errors invariably lead to compromise
with patient safety and can even lead to death of the patients. The researchers conducted a
cross sectional descriptive study where in a total of 327 nursing professionals were
considered as participants to investigate the primary causes that led to medication errors
within a clinical setting. The researchers collected data by means of questionnaire surveys
and analysed the obtained results by the use of statistical interpretation. The research results
suggested that the most common cause of medication error was due to increased work load

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(~97.8%) and incorrect drug calculation (~77.4%). Further the research findings of the
researchers suggested that incorporation of mentorship and improved guidance in terms of
knowledge about medication standards and side effects can help to improve overall patient
safety and promote positive patient outcome.
D Schiff et al. (2017), opined that integration of an advanced computerised provider
order entry can help to prevent medication errors that are related to ‘look alike sound alike’
medication orders. The researchers support their proposition with statistical data which
mentions that incorporation of computerised order entry helped to improve medication safety
by more than 10% to 70% within the United States of America. The proposal of the idea was
to popularise the scheme of electronic ordering of medication both inside as well as outside
the healthcare setting. The idea is to order the medication electronically and send the orders
electronically to the pharmacy companies. This could potentially avoid the risk of committing
medication errors and help to promote positive patient outcome. The researchers speculate
that lack of physician’s acceptance as well as lack of a standard electronic transmission
guideline can generate poor outcome. However, the overall conclusion of the researchers
suggest that integration of the automated ordering system would help to reduce medication
errors.
Marianne et al. (2016), conducted a pilot study to enhance the sensitivity of registered
nurses to risks and improve behaviours so as to reduce observed medication errors within
healthcare settings. The researchers believed that medication errors were preventable and
could efficiently be improved with the integration of change within the operation and
reporting system. It should be noted in this context that the researchers suggested that
conducting education and awareness workshops could help to prevent medication error and
contribute to positive patient outcome. Post the implementation of the education program, it
was observed that nurses perception and attitude to identify medication error was

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significantly improved. Also, the educational program helped to improve compliance with
safe medication standards and enhance patient safety. Hence, it can be mentioned that the
overall findings of the researchers suggested that support strategies for safer medication
practice could help to reduce the prevalence of medication errors within clinical care settings.
Foanio et al. (2017), suggested that the development and evaluation of an algorithm
for the detection of common medication errors can help to prevent errors that are similar to
‘look alike sound alike’ type of drugs. The computerised algorithm is equipped with
technology to identify and flag ‘look alike sound alike’ medication error by aligning the
diagnosis of the disorder with the prescribed medication. The overall findings of the
researchers mention that the use of automated methods for the process of medication orders
can help to reduce LASA medication errors.
Miller et al. (2016) stated that most of the medication errors were on account of poor
pharmacological knowledge about the Drug types and their impact on the overall health
outcome of the patients. Further, the most common medication error was largely attributed to
wrong route of administration. The most effective intervention to reduce medication error
included, conducting education programs that stress upon the compliance with the 5 R’S of
medication and improved knowledge about the use of the Universal Drug Index and the
process of reviewing prescribed medication. Incorporation of educational strategies can help
to acquire improved patient outcome and reduce the incidence of medication errors within a
healthcare environment.

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Implementation Strategy
In the rapidly altering healthcare environment, use of computer assisted devices and
technological improvements can challenge all healthcare professionals in a plethora of ways.
Implementation of a change in nursing practice within the healthcare environment often
results in the onset of fear and anxiety regarding failure, thereby causing resistance to the
changed practice (Gopee& Galloway, 2017). The evidences discussed in the previous section
suggest that medication errors that commonly occur in healthcare settings trigger in the onset
devastating outcomes for both the patient and the nurse. These negative outcomes can be
significantly reduced through the usage of technology that advances patient care and
enhances performance of the nursing professionals. Bar-coded medication administration has
been identified as onecategory of technology that is based on the usage of a scanning
equipment for comparing bar codes that are present on identification bands worn by patients
(Larson & Lo, 2019). These bar codes generally contain information about the prescribed
medications, following which they are electronically verified against the medicine records,
thusdecreasing medication error events. Hence, the improvement project will be based on
application of Lewin’s theory of management for successful implementation of bar-coded
medication administration.
Kurt Lewin’s theory have been implemented by several healthcare organisations in
order to gain a sound understanding of human behaviour, as it is associated to change
management, and different patterns of resistance. According to Hussain et al. (2018) also
referred to as the Lewin’s Force Field Analysis, the theory generally encompasses three
separate phases namely, unfreezing, moving, and refreezing (Cummings, Bridgman &
Brown, 2016). The primary intention behind implementing this model in the healthcare
setting is to recognise factors that can obstructthe anticipated change from happening, forces

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that compete with change,frequently called restraining or those that will promote the change,
mentioned as driving forces.
Application of the theory
The first step of unfreezing will involve communicating with the major stakeholders
at the hospital such as, the administration, managers and frontline nursing staff. The line of
communication will be kept honest and open, thus will help in establishing a sense of safety
and conviction in all stakeholders. Round table discussions will be initiated at this stage with
the sole intention of teasing out the restraining and driving forces (Cummings, Bridgman &
Brown, 2016). While some restraining forces can be poor computer literacy, lack of faith, and
aversion to new machinery, upper management support and sufficient financial investment
might act as driving forces. During the moving stage, bar coding will be implemented across
the healthcare facility and will necessitate the continueddetermination from numerous teams,
such as,pharmacy, information technology (IT), nursing, clinical information services (CIS),
clinical nurse educators, program managers, and administrators. The nursing staff will be
actively involved for developing a sense of possession, regarding efficacy and attainment of
the improvement of the project (Burnes&Bargal, 2017). The nurses will be trained to
interpret bar coding. A project leader will be asked to monitor and oversee the project at this
stage. During the final stage, continued technology support will be offered, till the change is
considered complete and the patients arecontented with the machinery.
As change occurs in an organisation, it is significant to observe and assess the
consequences of the change programme. This includesconnecting the changes to the
innovativeplan and purpose (Batras, Duff & Smith, 2016). If change is not assessed it will be
extremely problematic for the managers to explore the efficacy of bar-coding system in
reducing medication error. The strategy to be used for assessing the change is key
performance indicators (KPIs). These indicators will monitor how effectively the

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stakeholders have worked towards accomplishment of the intended objective (Hayes, 2018).
Taking into consideration the fact that the objective was to reduce medication error, a clinical
audit will be conducted prior to, and after implementation of the change management
program. The duration of this change management will be four months. Prior to the change
management, the nurses, pharmacists and physicians will be asked to participate in voluntary
reporting of medication error incidents, in addition to conducting chart review. After four
months, they will again be asked to perform the same procedure, following which the number
of events related to medication error that occurred in the hospital during the period will be
assessed. Decrease in the medication error events will confirm success of the change
management program.
Evaluating change management
In the contemporary eventful and demanding healthcare environment, nursing
professionals are generally anticipated to keep up with up-to-date cohesive technology,
frequently with little or no say regarding their impacts. Showing consistency with any new
modification, ‘buy in’ by the nurses who are in the front line is indispensable to ensure a
smooth change of the informatics project, owing to the fact that several nurses can be hesitant
and resistive to innovative computer aided equipment in practice. According to Amarantou et
al. (2017) management of change has continuously been thought-provoking in healthcare
amenities, and new machineries often provoke confrontation from nurses who by now cannot
find sufficient time during their work shift for completing patient associated tasks. Numerous
barriers have been recognised when applying a change in process of this scale together with
non-existence of collaboration between staff, dread of using innovative methods, and
confrontation to change in anticipation that the novel technology would not prove effective.

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Resistance to change management
One potential barrier that could influence the application of bar-coded medication
administration at the hospital is the likelihood of different patients declining to put on the
identification bands, which in turn is necessary for success of the project. In addition, other
barriers might comprise of shortcuts that certain nurses have implemented to save their time
and energy, such as, pre-pouring of medications, which breaches the basic nursing standards
of practice(Chai&Goldhirsch, 2019). This resistance can be overcome by allocating
appropriate roles and responsibilities to the stakeholders that will allow them to use their
expertise to the best advantage. In addition, breaking the innovation project into smaller
milestone, and celebrating the accomplishments of the nurses will prove beneficial.
Moreover, the seven methods of care-fronting will also be used for controlling
communicative breakdowns (Endrejat et al., 2017). It is also imperative to produce an upright
team spirit, while holding team bonding sessions. Creating opportunities for feedback and
displaying flexibility will also help in overcoming resistance to change, thereby facilitating
reduction of medication errors at the hospital.

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References
Addelman, M. (2019). More than 200 million medication errors occur in NHS per year, say
researchers. [online] More than 200 million medication errors occur in NHS per year,
say researchers. Available at: https://www.manchester.ac.uk/discover/news/more-
than-200-million-medication-errors-occur-in-nhs-per-year-say-researchers/ [Accessed
16 Sep. 2019].
Amarantou, V., Kazakopoulou, S., Chatzoglou, P., &Chatzoudes, D. (2017). Attitude Toward
Change: Factors Affecting Hospital Managerial Employees’ Resistance to Change.
In Strategic Innovative Marketing (pp. 251-257). Springer, Cham.
Ashcroft, D. M., Lewis, P. J., Tully, M. P., Farragher, T. M., Taylor, D., Wass, V., ...&
Dornan, T. (2015). Prevalence, nature, severity and risk factors for prescribing errors
in hospital inpatients: prospective study in 20 UK hospitals. Drug safety, 38(9), 833-
843.
Baqir, W., Crehan, O., Murray, R., Campbell, D., & Copeland, R. (2015). Pharmacist
prescribing within a UK NHS hospital trust: nature and extent of prescribing, and
prevalence of errors. Eur J Hosp Pharm, 22(2), 79-82.
Batras, D., Duff, C., & Smith, B. J. (2016). Organizational change theory: implications for
health promotion practice. Health promotion international, 31(1), 231-241.
Burnes, B., &Bargal, D. (2017). Kurt Lewin: 70 years on. Journal of Change
Management, 17(2), 91-100.
Chai, E., &Goldhirsch, S. (2019). That Was Then, This Is Now: Using Palliative Care
Principles to Guide Opioid Prescribing. Journal of palliative medicine, 22(6), 612-
614.

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Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps:
Rethinking Kurt Lewin’s legacy for change management. Human relations, 69(1), 33-
60.
Durham, M. L., Suhayda, R., Normand, P., Jankiewicz, A., &Fogg, L. (2016). Reducing
medication administration errors in acute and critical care: multifaceted pilot program
targeting RN awareness and behaviors. JONA: The Journal of Nursing
Administration, 46(2), 75-81.
Elliott, R., Camacho, E., Campbell, F., Jankovic, D., St James, M. M., Kaltenthaler,
E., ...&Faria, R. (2018). Prevalence and economic burden of medication errors in the
NHS in England. Rapid evidence synthesis and economic analysis of the prevalence
and burden of medication error in the UK.
Endrejat, P. C., Müller, L., Klonek, F. E., &Kauffeld, S. (2017). How to Respond to
Resistance to Change? An Analysis of Change Agents’ Communication Behaviors.
In Academy of Management Proceedings (Vol. 2017, No. 1, p. 14281). Briarcliff
Manor, NY 10510: Academy of Management.
Goedecke, T., Ord, K., Newbould, V., Brosch, S., &Arlett, P. (2016). Medication errors: new
EU good practice guide on risk minimisation and error prevention. Drug safety, 39(6),
491-500.
Gopee, N., & Galloway, J. (2017). Leadership and management in healthcare. Sage.
Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., &Yaghoobi, M. (2016). Investigating the
causes of medication errors and strategies to prevention of them from nurses and
nursing student viewpoint. Global journal of health science, 8(8), 220.
Hayes, J. (2018). The theory and practice of change management. Palgrave.

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Healthcare Conferences UK. (2019). Monitoring & Reducing Medication Errors in Hospitals
National Conference 2019. Retrieved from
https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/monitoring-
reducing-medication-errors-in-hospitals-national-conference-2019
Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt
Lewin's change model: A critical review of the role of leadership and employee
involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-
127.
Larson, K., & Lo, C. (2019). Potential Cost Savings and Reduction of Medication Errors Due
to Implementation of Computerized Provider Order Entry and Bar-Coded Medication
Administration in the Fraser Health Authority. UBC Medical Journal, 10(2).
Miller, K., Haddad, L., & Phillips, K. D. (2016). Educational strategies for reducing
medication errors committed by student nurses: a literature review. International
Journal of Health Sciences Education, 3(1), 2.
Nanji, K. C., Patel, A., Shaikh, S., Seger, D. L., & Bates, D. W. (2016). Evaluation of
perioperative medication errors and adverse drug events. The Journal of the American
Society of Anesthesiologists, 124(1), 25-34.
Rodziewicz, T. L., &Hipskind, J. E. (2019). Medical error prevention. In StatPearls
[Internet]. StatPearls Publishing.
Rose, A. J., Fischer, S. H., &Paasche-Orlow, M. K. (2017). Beyond medication
reconciliation: the correct medication list. Jama, 317(20), 2057-2058.

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Schiff, G. D., Hickman, T. T. T., Volk, L. A., Bates, D. W., & Wright, A. (2016).
Computerised prescribing for safer medication ordering: still a work in progress. BMJ
QualSaf, 25(5), 315-319.
TOLLEY, C. (2018). An investigation of healthcare professionals’ experiences of training
and using electronic prescribing systems: four literature reviews and two qualitative
studies undertaken in the UK hospital context.
Triggle, N. (2018). Drug errors cause appalling harm and deaths, says Hunt.Retrieved from
https://www.bbc.com/news/health-43161929
World Health Organization. (2016). Medication errors. Retrieved from
https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-
eng.pdf;jsessionid=2819838E81257EDE92D19F9F111032EA?sequence=1

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Appendix 1: