NR 544 Week 5 Medication Errors

NR 544 Week 5 Medication Errors

Student Name

Chamberlain University

NR-544: Quality & Safety in Healthcare

Prof. Name:

Date

Medication Errors and Patient Safety: Risk Evaluation and Prevention

Abstract

This paper explores the critical issue of medication errors in healthcare, focusing on risk evaluation and patient safety. Various risk factors contributing to medication errors are analyzed, along with potential strategies to minimize their occurrence. Both internal and external factors influencing medication errors are identified, utilizing the Swiss Cheese model as a framework for preventing future errors. Additionally, recommendations are provided to encourage nurses to report medication errors, fostering a culture of transparency and continuous improvement in healthcare settings.

Medication Errors and Patient Safety

Healthcare is a complex field that involves multiple disciplines, requiring precision and attention to detail. Given the intricacies of healthcare delivery, errors—particularly medication errors—are an unfortunate yet inevitable aspect of the profession. Nurses, often working under high-pressure conditions and short staffing, may inadvertently administer the wrong medication to a patient. These errors can have severe consequences, especially if the patient has an unknown allergy to the medication. This paper addresses the issue of medication errors by examining the associated risk factors, discussing relevant risk theories, and proposing solutions to mitigate such errors.

Patient Safety Strategies

Ensuring patient safety requires a multifaceted approach that acknowledges the root causes of medication errors. While no single solution can completely eliminate these errors, understanding why they occur is a crucial first step. Open discussions between nurses and healthcare providers can shed light on the factors leading to errors and help in developing effective prevention strategies. When a medication error occurs, informing the patient is essential not only to maintain transparency but also to assess any potential adverse effects (Russell, 2018). Additionally, reducing interruptions during medication administration, such as minimizing disruptions during medication passes, can significantly lower the likelihood of errors.

Literature Review

Research by Russell (2018) highlights the importance of risk management discussions following a medication error. These discussions provide insight into the causes of errors, facilitate learning, and empower nurses to report future incidents. Similarly, Beverly et al. (2018) emphasize that nurses who feel supported and encouraged to evaluate their mistakes are more likely to report errors and implement corrective measures. However, fear of scrutiny often prevents nurses from self-reporting errors (Brennan et al., 2016). To address this issue, healthcare organizations must establish a supportive environment where nurses feel safe to disclose errors without fear of punishment.

In psychiatric settings, the Safewards model has been successfully implemented to improve safety by reducing conflict and encouraging collaborative risk management (Bungay, Jenkins, & Slemon, 2017). This model promotes a team-based approach to patient safety, ensuring that medication errors and other risks are addressed collectively rather than placing blame on individual staff members. Furthermore, research indicates that nurses are more likely to report medication errors when they perceive a benefit from doing so, such as improved patient care and professional development (Brennan et al., 2016).

Contributing Factors

Several internal and external factors contribute to medication errors and nurses’ reluctance to report them. Internally, poor communication, inadequate quality control, ineffective risk management, and weak nursing leadership can increase the likelihood of errors. Externally, a lack of institutional support, insufficient resources, inadequate training facilities, and poor departmental leadership further exacerbate the problem. Addressing these factors requires a comprehensive approach that involves organizational changes, policy enhancements, and ongoing education.

Risk Theories and Applications

The Swiss Cheese model provides a valuable framework for analyzing and preventing medication errors (Chamberlain University College of Nursing, 2021). In this model, multiple layers of defense exist within a healthcare system, but each layer has potential vulnerabilities represented as holes. Medication errors occur when these holes align, allowing errors to pass through unchecked. The model emphasizes the importance of implementing multiple safety barriers to catch and rectify errors before they reach the patient. The first step in applying this model is identifying vulnerabilities in the medication administration process. Subsequent steps involve improving existing safety measures, maintaining strict monitoring procedures, and implementing new strategies to strengthen defenses against medication errors.

QSEN Competencies: Safety and Evidence-Based Practice

Two key Quality and Safety Education for Nurses (QSEN) competencies relevant to this discussion are safety and evidence-based practice (EBP). Safety is a primary concern, as medication errors can lead to severe patient harm, legal consequences for nurses, and reputational damage to healthcare institutions. EBP plays a crucial role in addressing medication errors by guiding best practices for medication administration, error prevention, and patient safety measures. Research-driven interventions, such as standardized medication labeling, barcode scanning, and double-checking high-risk medications, can significantly reduce the risk of medication errors. Additionally, EBP supports initiatives such as ensuring adequate staffing, minimizing interruptions during medication passes, and implementing patient identification protocols to prevent errors.

Conclusion

Medication errors remain a critical issue in healthcare, influenced by a range of internal and external factors. Identifying the root causes of these errors and implementing evidence-based solutions is essential to improving patient safety. Encouraging nurses to report errors without fear of punishment can foster a culture of transparency and continuous improvement. Supportive leadership, effective risk management strategies, and structured safety frameworks such as the Swiss Cheese model can help prevent medication errors. Ultimately, a collaborative and proactive approach is necessary to enhance medication safety and protect patient well-being.

Table: Key Aspects of Medication Errors and Patient Safety

References

Beverly, C., Deshpande, J., Green, A., Heo, S., Middaugh, D., & Trevino, P. (2018). Nursing perception of risk in common nursing practice situations: Risk management. Journal of Healthcare Risk Management, 37(3), 19–28. https://doi.org/10.1002/jhrm.21283

Brennan, M., Costello, P., Downes, C., Doyle, L., Higgins, A., Morrissey, J., & Nash, M. (2016). There is more to risk and safety planning than dramatic risks: Mental health nurses’ risk assessment and safety-management practice. International Journal of Mental Health Nursing, 25(2), 159–170. https://doi.org/10.1111/inm.12180

Bungay, V., Jenkins, E., & Slemon, A. (2017). Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nursing Inquiry, 24(4), e12199–n/a. https://doi.org/10.1111/nin.12199

NR 544 Week 5 Medication Errors

Chamberlain University College of Nursing. (2021). NR-544 Week 4: Quality and Safety in Healthcare [Online Lesson]. https://chamberlain.instructure.com/login/canvas

Russell, D. (2018). Disclosure and apology: Nursing and risk management working together. Nursing Management, 49(6), 17–19. https://doi.org/10.1097/01.NUMA.0000533773.14544.e2