Running head: ENHANCING QUALITY AND SAFETY 1

Enhancing Quality and Safety

Claude Mua

Capella University

Improving Quality of Care and Patient Safety

Dr Lisa Newton

November 2021
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Specific Patient-safety Risk

Medication error is an excellent example of a specific patient-safety risk focusing on

medication administration. Medication error is any preventable event causing/leading to

inappropriate medication use or patient harm while healthcare professionals, consumers, or the

patient may be in control (Tariq et al., 2021). Medication error occurs in different steps of

medication administration. The error may occur in the ordering/prescribing, transcribing,

administering, documenting, dispensing, and monitoring (Tariq et al., 2021). The errors

commonly occur during the ordering/prescribing stage, for example, a provider writing a wrong

medication, wrong frequency, and wrong route/dosage.

Although medication error is unintentional, it hurts patient and their families. Moreover,

these errors may further contribute to healthcare professionals' adverse emotional and mental

effects (Robertson & Long, 2018). Medication errors cause avoidable harm and injuries for the

patients, and the associated costs are very high. For example, medication errors will lead to

increased hospitalization and may also result in the patient’s death. Physicians and providers feel

adverse emotions after the occurrence of an error, such as shame, guilt, depression, fear, and

anxiety (Robertson & Long, 2018). Errors will occur due to many reasons, such as the lack of

concentration, burnout, posttraumatic stress disorder, depression, and poor work performance.

Evidence-based and Best-Practice Solutions

Medication administration errors are amongst the common errors occurring when there is

a discrepancy in the medication process. The occurrence causes a lot of injury/death to the

patient, and it is usually unintentional. Addressing these errors would require a modification of

the healthcare system and make it difficult for provides to carry out incorrect actions and easier

for them to adhere to correct actions/measures (Rodziewicz et al., 2021). Although individuals
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need to be held accountable for these errors, the system, and healthcare environment culture need

revision to streamline operations and make it easier to report errors. Below are examples of

evidence-based approaches to addressing medication errors.

The first approach is to re-educate the provider on the five rights of medication – right

patient, drug, route, time, and dose. For example, in the case of the ‘right patient,’ the provider

must ascertain the patient being treated by directly asking the patient questions, such as

providing his/her full name or confirming the medical wristbands to check whether the name and

ID number match (Hanson & Haddad, 2021). Moreover, a nurse/provider must ensure that the

administered medication is identical to the prescribed drug name. The nurse must discern since,

on many occasions, some names might look/sound similar because of the suffix, prefix, or in that

they start with a similar first letter. Overall, mastering the five rights for all practitioners will

help since they are more like a first-line defense system that a healthcare facility must adopt.

The second evidence-based approach regards the use of technology as a facilitator or

support to the five rights. For example, the use of Electronic Health Record (EHR) may help

with the written information. Although they are also prone to errors, such as charting

information/placing orders on the wrong patients, clinicians must use this alongside the five

rights to verify every information/process (Rodziewicz et al., 2021). Furthermore, another

critical technology includes automating dispensing devices, computerized medication

administration records, and computerized order entry. A computerized provider order entry

system can reduce medical errors by about 50% (Rodziewicz et al., 2021). These systems and

technologies must be facilitated by the five rights of the medication process.

Nurses and Coordination of Care

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The safety of patients is a priority during the provision of care characterized by safety

and quality measures. Nurses are integral to the subject of patient safety. They help coordinate

care while looking to reduce errors, risks, and harm to patients. There are different ways that

nurses can help coordinate care through the medication administration process to ensure safety.

For example, a nurse can double-check the dosage and the frequency of all the high-alert

medications. They need to engage pharmacists and physicians if unsure about a medication

prescribed or dosage. Also, nurses can re-check calculations and establish that a therapeutic

dosage is right (Hanson & Haddad, 2021). Besides, nurses must ensure adherence to the ‘five

rights’ during the medication administration process, including the right patient, drug, route,

time, and dose (Hanson & Haddad, 2021).

Moreover, an important element in the coordination process is communication.

Communication improves coordination providing exceptional patient care with decreased

mortality and morbidity (Tariq et al., 2021). For example, pharmacists should communicate

effectively with team members, such as clinicians and nurses. In such a communication, since

errors commonly occur during the ordering/prescribing stage, pharmacists should confirm

understanding, document any decision and conversation, confirm the order, repeat the order

changes, even do medication reconciliation, and confirm any written errors. Furthermore,

teamwork is another important concept. An environment characterized by teamwork is the most

optimal and conducive to medication delivery. The team should understand the role and

responsibilities of each member and should not fear discussing and resolving conflicts (Tariq et

al., 2021). Discussion amongst team members should be encouraged since these discussions and

communication limit the discovery of medication errors and conflict resolutions.

Stakeholders
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As part of an interdisciplinary team, nurses play a significant role with other medical

providers and other healthcare workers. The immediate stakeholders are members of the

interprofessional team working together, looking to achieve accurate medication and decrease

errors (Tariq et al., 2021). In the medication administration process, clinicians are responsible for

ordering medications; pharmacists fill these medications while nurses and/or patients administer

the medications. Apart from these care-related stakeholders, other stakeholders that nurses

coordinate with to emphasize safety enhancements with medication administration include the

administration, nurse leadership, family members, and professional associations.

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References

Hanson, A., & Haddad, L., M. (2021). Nursing Rights of Medication Administration. Retrieved

from https://www.ncbi.nlm.nih.gov/books/NBK560654/

Robertson, J. J., & Long, B. (2018). Suffering in Silence: Medical Error and its Impact on Health

Care Providers. The Journal of emergency medicine, 54(4), 402–409.

https://doi.org/10.1016/j.jemermed.2017.12.001

Rodziewicz, T.L, Houseman, B. & Hipskind, J. E. (2021). Medical Error Reduction and

Prevention. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499956/

Tariq, R., A, Vashisht, R., Sinha, A. & Scherbak, Y. (2021). Medication Dispensing Errors and

Prevention. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519065/