Analyzing a Current Health Care Problem or Issue

Medication errors are a common healthcare concern worldwide, contributing to adverse patient outcomes, heightened medical costs, and decreased trust in the healthcare system. Nurses committing medication errors face long-term emotional and legal consequences that impede effective nursing practices. This assessment is a continuation of the medication error experience that occurred during my orientation period during my clinical placement at the cardiovascular intensive care unit. This paper examines the issues and discusses potential ethical solutions to address the growing concern. 

Elements of the Problem/Issue

Drug-related errors are considered one of the most substantial medical errors, known to be the third principal cause of patient mortality in the United States. It is primarily committed by nurses, mainly nursing students, which accounts for 39.68% of errors in an Iranian study (Tabatabaee et al., 2022). According to the World Health Organization (WHO), 1.3 million individuals in the United States encounter one or the other types of adverse drug injuries due to medication errors, which costs approximately $42 billion to manage the impacts of the mistakes (Naseralallah et al., 2023). These errors result in severe poor results for care consumers and healthcare systems. Patients may experience adverse drug reactions, prolonged hospital stays, and enhanced likelihood of death. Moreover, these errors also lead to augmented treatment costs owing to longer hospital stays (Tabatabaee et al., 2022). Furthermore, they can damage the trust between patients and healthcare providers and contribute to professional and emotional distress for healthcare workers involved in the errors (Tariq & Scherbak, 2024). Medication errors compromise patient safety and highlight the need for improved systems and practices in healthcare to prevent such incidents.

The chosen information is relevant because it provides a comprehensive understanding of the scope and impact of medication errors. The data from reputable sources and peer-reviewed journals lend credibility to the discussion and help healthcare professionals and policymakers recognize the urgency of addressing this issue through evidence-based interventions and fostering a culture of safety in healthcare settings.

Analyze the Problem or Issue

Medication errors, defined as preventable mistakes in prescribing, dispensing, or administering medications, pose significant risks to patient safety (Naseralallah et al., 2023). This issue stems from the error that occurred due to the oversight of a critical instruction in the medication administration record (MAR) in the cardiovascular unit during the orientation period. Several factors lead to medication errors among nurses, including workload distractions, miscommunication, and lack of experience. In a study, nurses reported that 11.3% of drug-related mistakes occur due to constant interruptions during the medication administration process. These distractions can be related to patient-care activities, urgent tasks, and increased workload (Isaacs et al., 2023). Other factors illustrated by the study include a lack of appropriate hands-off communication and skill deficits among nursing professionals, as highlighted within the scenario. 

Medication errors are a significant issue across all healthcare settings, including inpatient hospitals, outpatient clinics, and nursing home facilities. In high-pressure environments like intensive care units, where patients are often critically ill, the chances of these errors increase due to complex patient issues, frequent use of high-risk medications, and the need for precise monitoring (Laher et al., 2021). Several stakeholders are impacted due to these drug-related adverse events. Patients are the most directly affected, facing potential harm or complications from incorrect medication administration. According to Tariq and Scherbak (2024), healthcare providers, including nurses and physicians, are also affected, as such errors can lead to professional and emotional stress, disciplinary actions, and a loss of trust from patients. The healthcare system itself suffers from increased costs associated with additional treatments and more extended hospital stays (Naseralallah et al., 2023). This issue emphasizes the need for comprehensive education, robust systems, and supportive environments to reduce the incidence of medication errors.

This healthcare concern is essential to new graduate nurses because it highlights the critical nature of their role in patient safety. Nurses are primarily responsible professionals for administering medications, thus are crucial to prevent medication mistakes by paying close attention to medication administration records and following protocols precisely (Wondmieneh et al., 2020). Addressing this issue in the early stages of careers is essential for building confidence, ensuring patient safety, and fostering a culture of accountability and excellence in nursing practice. 

Considering Options and Proposed Solution 

Multiple ways exist to address the risk of medication errors in healthcare settings, such as comprehensive staff training, technological implementation, and strengthening communication and teamwork. This assessment focuses on staff training and the implementation of Barcode Medication Administration (BCMA) systems to mitigate patient safety risks associated with medication administration. 

To implement staff training, healthcare institutions must invest in comprehensive orientation programs, including simulation-based learning, workshops, and mentorship. Regularly scheduled refresher courses and training on medication administration practices are essential to keep nurses updated on best practices and evolving guidelines (Rani, 2020). These training programs will offer access to online modules and peer support networks, reinforcing the importance of medication safety through standardized administration practices and improving overall nursing competencies. Eventually, the goal is to reduce medication errors through effective nursing practices (Rani, 2020). While these training programs are beneficial, they can be time-consuming and costly to implement. Additionally, it may add a burden to nursing schedules due to intensive training, potentially leading to burnout. Thus, it is crucial to balance the need for comprehensive education with the practical demands of a busy healthcare environment. 

Another crucial solution is leveraging technology, such as Barcode Medication Administration (BCMA) systems, to minimize drug-related errors by automating medication checks and offering real-time alerts for mistakes (Mulac, 2021). These tools help ensure that the correct medication is administered at the right dose and time by cross-referencing patient information and current lab results. Implementing BCMA requires significant planning, including the acquisition and integration of barcode scanning devices and compatible software within the electronic health record (EHR) system. Additionally, it is crucial to train staff on how to use the BCMA system effectively to ensure seamless adoption. Poor implementation of BCMA can lead to workflow disruption, increased workload due to errors, and an increase in the incidence of medication errors (Mulac, 2021). Moreover, implementing BCMA involves significant financial investment, which may be challenging for some healthcare institutions. Finally, over-reliance on BCMA might lead to satisfaction, where nurses trust the system and overlook critical thinking, potentially causing errors. 

Outcomes of Not Addressing the Issue

Failure to address medication errors within the organization can further exacerbate the situation, leading to patient morbidity and mortality and loss of patient trust in the healthcare system. It also leads to additional healthcare costs owing to lengthier hospital admissions and further treatments. For new graduate nurses, repeated errors can result in professional setbacks, legal repercussions, and emotional distress. Wondmieneh et al. (2020) mention that failure to address medication errors can erode the safety culture within an organization, leading to a higher incidence of adverse events and diminishing the quality of care provided. 

Ethical Implications of the Proposed Solution 

Ethical principles of autonomy (respect for patients’ rights), beneficence (to benefit), non-maleficence (to not harm), and justice (fair and equitable) are crucial in clinical practices, including solutions to address medication errors (Varkey, 2021). Implementing enhanced staff training is interlinked with the ethical principles of beneficence and nonmaleficence, as the objective is to enhance patient outcomes and reduce the risk of harm from medication errors. By equipping nurses with the knowledge and skills necessary to administer medications safely, healthcare providers act in the best interest of patients (Rani, 2020). Autonomy is respected by empowering nurses with the competence to make informed decisions in clinical settings. Finally, justice is upheld by ensuring that all nurses, regardless of experience level, receive equal access to comprehensive training, fostering a fair and safe environment for both patients and staff. Similarly, executing BCMA technology implies the ethical principles of beneficence and nonmaleficence by providing an additional safeguard against medication errors, thereby enhancing patient safety. The system promotes justice by standardizing medication administration practices across the healthcare setting, ensuring that all patients receive the same level of care (Mulac, 2021). However, autonomy must be balanced, as the reliance on technology could potentially reduce nurses’ decision-making capabilities. To address this, it’s crucial to maintain a role for human oversight and critical thinking. 

Conclusion

In conclusion, this assessment explored the critical issue of medication errors, particularly from the perspective of a new graduate nurse in a cardiovascular intensive care unit. Several causes, such as frequent distractions, communication barriers, and lack of experience, lead to such issues in critical care areas. Thus, solutions, including enhanced education and training and the implementation of BCMA, are proposed to mitigate the risks of medication errors. While these solutions offer potential benefits, they also present challenges and ethical considerations, particularly in balancing patient safety with the autonomy and equitable treatment of nurses. Addressing medication errors through these strategies is essential for improving patient outcomes and fostering a safer healthcare environment.

References

Isaacs, A., Raymond, A., & Kent, B. (2023). Content analysis of nurses’ reflections on medication errors in a regional hospital. Contemporary Nurse, 59(3), 1–20. https://doi.org/10.1080/10376178.2023.2220432 

Laher, A. E., Enyuma, C. O., Gerber, L., Buchanan, S., Adam, A., & Richards, G. A. (2021). Medication errors at a tertiary hospital intensive care unit. Cureus, 13(12), e20374. https://doi.org/10.7759/cureus.20374 

Mulac, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. British Medical Journal Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 

Capella FPX 4000 Assessment 5

Naseralallah, L., Stewart, D., Price, M. J., & Vibhu Paudyal. (2023). Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: A systematic review. International Journal of Clinical Pharmacy, 45(6), 1359–1377. https://doi.org/10.1007/s11096-023-01626-5 

Tabatabaee, S. S., Ghavami, V., Javan-Noughabi, J., & Kakemam, E. (2022). Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: A retrospective study of medical records. BMC Health Services Research, 22(1), 1420. https://doi.org/10.1186/s12913-022-08864-9 

Rani, S. (2020). To study the effectiveness of the training program on safe administration of drugs to reduce the medication error. Indian Journal of Holistic Nursing, 11(03), 12–19. https://doi.org/10.24321/2348.2133.202003 

Tariq, R. A., & Scherbak, Y. (2024). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Capella FPX 4000 Assessment 5

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119 

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0