Medication Errors: Analysis, Strategies, PDSA Cycle & NSW Policies

This report provides a comprehensive analysis of medication errors within the healthcare system, particularly focusing on the context of New South Wales (NSW). It defines medication errors, outlines their various types (knowledge-based, rule-based, action-based, memory-based, and technical), and identifies factors contributing to these errors, such as communication problems, distractions, and inadequate training. The report discusses the consequences of medication errors for both patients and healthcare professionals, emphasizing the importance of prevention. It highlights the role of nurses as gatekeepers in medication administration and recommends strategies for error reduction, including the implementation of the PDSA (Plan, Do, Study, Act) cycle for continuous improvement. The report also references NSW health policies related to medication management and concludes with recommendations for enhancing medication safety and providing quality healthcare services. Access to the full document and related resources is available on Desklib, a platform offering AI-powered study tools and a wide range of solved assignments.

Medication errors

Medical error-definition
 Medication error refers to the errors that could be prevented by the health care
professional while prescribing medicines.
 These errors involve issues such as giving wrong dosage , wrong medication or using
incorrect ways of administration.

Aim for medication error
The objectives of model for improvement in medication errors are as follows:
To improve the medication errors.
The aim is limited to the stakeholder satisfaction.

PSDA Cycle
 PSDA Cycle stands for Plan, Do, Study and Act.
 It is the four stage model which us used for improving the process fro carrying out a
change.
 It focus on including internal and external customers through which they are able to
provide feedback on what can work and what cannot.
 In simple words, this model concentrates on carrying out test and observing and
learning from the study (consequences) which help in determining what changes should
be made in Act (test).

Continued..
P-Plan
It includes collection of demographic data associated with the patient, omissions, drug
allergy documentation and their medication
It is also involved in identify patients who are taking any of 4 classes of medicines which
are more likely to cause severe harm and death.
D-Do
In this plan is put into action
Data is collected which helps in evaluation of plan

Continued..
S-study
In this step the results of plan are evaluated.
The improvements are reviewed and evaluated.
A-Act
In this step, plan is reflected and outcomes are evaluated.

Policies of NSW in medication
 Policy of NSW Health department associated with medication error consolidates best
practices such s principles on medication storage, prescribing, supply, dispensing,
administration and procurement as well.
 This policy applies to all public health organization health facilities and other institutes
such as hospitals, clinical services, community health centres and hospitals as well.
 However, his policy is not applicable to medication handling and administration
thorough flight nurses and paramedics employed by NSW ambulances.

Model for improvement
 It is a framework which is used of development, testing as well as for implementing
changes which lead to improvements.
 It provides easy to understand scientific method that acts to moderate the impulsive for
taking immediate course of action with the help and wisdom of a careful study.

CASE FOR CHANGE
 Medication error are considered a significant problem in the Australia in compared to
other countries. According to the reports it has been estimated that around 2%-3%
health care issues in Australian hospital admission is related to medication errors only.
 In other words it can be said that around 230,000 admission in the country are caused
due to patients taking too much or too little medication annually.

MODEL FOR IMPROVEMENT
 With the use of PDSA Cycle changes for improvement can be inculcated. According to
author, Plan Do Study Act is a four stage interactive problem solving model that is used
for improving a process and carrying out the changes in the processes.
 In other words, according to the view point of author, the PDSA cycle begins with the
step of planning that is using of theories and analysing the success metrics, further
these activities are followed by the do step that is where the plan in implemented.
 In third step the implemented step in studies and analysed. And lastly the act step
which closes the cycle , generated by the entire process.

CONTD…
To reduce medication errors and to improve quality health care
 It can be analysed that medication error is one of the most serious problem in the
health care system of NSW. Health care professional plays a major role in preventing and
catching these medication. It can be analysed there are various types of medication error
that is prescribing, omission, wrong times, unauthorised drug, improper dose etc.
thus it is very important that some strategies are followed buy the health care professional
so that these errors could be prevented that is while prescribing medicines professional
should double check the prescription.