Updated:

Healthcare System Failures and Medication Errors Case Study

Exclusively available on Available only on IvyPanda® Made by Human No AI

Introduction

In the present case, two primary system failures were caused by medication dispensing and administration errors. First, the pharmacy issued the two chemotherapy medications prescribed to the patient on the same day. One of the medications was intravenous, and the other was intrathecal. However, the national guidelines require pharmacies to obtain written proof that intravenous medications had been given before dispensing intrathecal drugs.

Second, the doctors injected vincristine intrathecally instead of methotrexate, leading to severe complications for the patient. The two system failures indicate problems with compliance with national guidelines and local procedures in the unit. Both issues can be addressed through comprehensive interventions targeting errors’ root causes.

Solution 1: Increase the Control of Medication Dispensing

Safety is among the key QSEN competencies discussed during the course, and hence, it is crucial to ensure that there is adequate oversight of medication dispensing procedures. Research shows that pharmacists play a key role in preventing medication errors, such as preventable adverse drug events and dispensing mistakes (Wang et al., 2015). In the selected case, the pharmacist could have prevented the error by informing about the risks and participating in decision-making. Hence, in order to increase the control of medication dispensing, it important to address the barriers to pharmacists’ involvement by using shared decision-making, training in interdisciplinary collaboration, and reporting of medication risks by the pharmacy (Figure 2).

It would also be useful to ensure adequate staffing of the pharmacy and timely updates on the register so that the dispensing process would go more smoothly, and there would be no distractions (Figure 2). Additionally, leaders of the hospital should also address compliance with the policy on all levels by offering training on national guidelines and creating controls to monitor compliance with guidelines and protocols for medication dispensing (Figure 2). Goldspiel et al. (2015) advise designing checkpoints for the entire process of medication dispensing and training pharmacists to follow each checkpoint carefully.

Solution 2: Increase Compliance with Medication Administration Guidelines

Here, the critical QSEN competencies to consider are patient-centered care, collaboration and teamwork, and safety. Improving staffing with qualified doctors and rescheduling late patients to eliminate time pressure would help to reduce environmental concerns leading to errors (World Health Organization, 2016). Additionally, it would be helpful to enhance interdisciplinary teamwork and communication through training and involve patients in procedure preparations (Figure 4). Roles and responsibilities of each employee should be clearly defined so that it would be possible to enhance oversight (WHO, 2016).

Other possible solutions would be improving labels on medications and placing clear labels on fridges for intrathecal drugs. According to the WHO (2016), such environmental controls may be useful in reducing administration risks. Finally, leaders should take part in enhancing policy and procedure compliance among employees (WHO, 2016). This would require implementing rigid procedures for checking medication charts and doctor’s authorization, as well as adequate monitoring methods (Figure 4). The organization would also benefit from providing induction and training before employees can take parts in procedures.

System failure 1.
Figure 1. System failure 1.
Solution 1.
Figure 2. Solution 1.
System failure 2.
Figure 3. System failure 2.
Solution 2.
Figure 4. Solution 2.

References

Goldspiel, B., Hoffman, J. M., Griffith, N. L., Goodin, S., DeChristoforo, R., Montello, C. M.,… Patel, J. T. (2015). ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. American Journal of Health-System Pharmacy, 72(8), e6-e35.

Wang, T., Benedict, N., Olsen, K. M., Luan, R., Zhu, X., Zhou, N.,… Shi, L. (2015). Effect of critical care pharmacist’s intervention on medication errors: A systematic review and meta-analysis of observational studies. Journal of Critical Care, 30(5), 1101-1106.

World Health Organization. (2016). Web.

More related papers Related Essay Examples
Cite This paper
You're welcome to use this sample in your assignment. Be sure to cite it correctly

Reference

IvyPanda. (2021, September 17). Healthcare System Failures and Medication Errors. https://ivypanda.com/essays/healthcare-system-failures-and-medication-errors/

Work Cited

"Healthcare System Failures and Medication Errors." IvyPanda, 17 Sept. 2021, ivypanda.com/essays/healthcare-system-failures-and-medication-errors/.

References

IvyPanda. (2021) 'Healthcare System Failures and Medication Errors'. 17 September.

References

IvyPanda. 2021. "Healthcare System Failures and Medication Errors." September 17, 2021. https://ivypanda.com/essays/healthcare-system-failures-and-medication-errors/.

1. IvyPanda. "Healthcare System Failures and Medication Errors." September 17, 2021. https://ivypanda.com/essays/healthcare-system-failures-and-medication-errors/.


Bibliography


IvyPanda. "Healthcare System Failures and Medication Errors." September 17, 2021. https://ivypanda.com/essays/healthcare-system-failures-and-medication-errors/.

If, for any reason, you believe that this content should not be published on our website, please request its removal.
Updated:
This academic paper example has been carefully picked, checked and refined by our editorial team.
No AI was involved: only quilified experts contributed.
You are free to use it for the following purposes:
  • To find inspiration for your paper and overcome writer’s block
  • As a source of information (ensure proper referencing)
  • As a template for you assignment
Privacy Settings

IvyPanda uses cookies and similar technologies to enhance your experience, enabling functionalities such as:

  • Basic site functions
  • Ensuring secure, safe transactions
  • Secure account login
  • Remembering account, browser, and regional preferences
  • Remembering privacy and security settings
  • Analyzing site traffic and usage
  • Personalized search, content, and recommendations
  • Displaying relevant, targeted ads on and off IvyPanda

Please refer to IvyPanda's Cookies Policy and Privacy Policy for detailed information.

Required Cookies & Technologies
Always active

Certain technologies we use are essential for critical functions such as security and site integrity, account authentication, security and privacy preferences, internal site usage and maintenance data, and ensuring the site operates correctly for browsing and transactions.

Site Customization

Cookies and similar technologies are used to enhance your experience by:

  • Remembering general and regional preferences
  • Personalizing content, search, recommendations, and offers

Some functions, such as personalized recommendations, account preferences, or localization, may not work correctly without these technologies. For more details, please refer to IvyPanda's Cookies Policy.

Personalized Advertising

To enable personalized advertising (such as interest-based ads), we may share your data with our marketing and advertising partners using cookies and other technologies. These partners may have their own information collected about you. Turning off the personalized advertising setting won't stop you from seeing IvyPanda ads, but it may make the ads you see less relevant or more repetitive.

Personalized advertising may be considered a "sale" or "sharing" of the information under California and other state privacy laws, and you may have the right to opt out. Turning off personalized advertising allows you to exercise your right to opt out. Learn more in IvyPanda's Cookies Policy and Privacy Policy.

1 / 1