Abstract
The majority of medication errors can be traced to inadequate information background, gaps in nurse practitioner training, unsystematic nature of prescriptions, and administrative shortfalls. Upon closer inspection, several underlying causes emerge, such as inadequate workplace conditions, lack of proper management, and gaps in communication (both among the nurses and between nurses and patients). A number of interventions can be suggested for implementation to improve the outcome. They include patient involvement, patient education, automatization of the prescription process using computerized solutions, promoting shared responsibility, and limited use of lean management.
Admittedly, some of the interventions require significant budgeting while others rely heavily on the support from the hospital officials, which creates the necessity of seeking budgeting support and establishing communication channels with the administrative branch, respectively. To minimize the resistance introduced by these factors, it is necessary to facilitate interventions in correct order, carefully schedule the process, monitor and log its success, and maintain communication channels with the stakeholders.
Lean Management
One of the factors responsible for the medication errors is the workplace environment in which nursing practitioners prescribe and administer drugs. Specifically, several studies have established a positive connection between the presence of interruptions during the process and the frequency of medication administration errors (MAE), which comprise 34% of the preventable adverse drug events (Lehnbom, Oliver, Baysari, & Westbrook, 2013). One of the ways to minimize the interruptions is an implementation of lean culture in nursing practices. Lean approach is steadily gaining its popularity as an effective way of improving performance and quality of services across various institutions, including healthcare establishments (Steyrer, Schiffinger, Huber, Valentin, & Strunk, 2013).
One of its advantages is its cost-efficiency – compared to other interventions, it requires little to no external funding, is easy to implement, and produces observable and measurable results. Another strong point is its transparency and flexibility – it can be applied to virtually any field with few adjustments and is approachable by the majority of the staff without special training. Finally, it can be performed within the nursing environment by using available organizational and administrative channels and thus does not require serious alternations of policies.
The first step in the intervention is communicating the principles of lean culture both to the staff and the management of the establishment. It is important to explain its main underlying principles, such as waste. In the case of workplace environment susceptible to medication errors, the most likely candidates for waste would be unnecessary interruptions, such as non-essential conversations, which would distract nurses from the prescription process and lead to erroneous results. Another possible waste is the presence of distracting factors in the workplace which accompany the prescription process. Simultaneously, the benefits of lean culture should be illustrated.
These should not be restricted to the quality of service, which is the usually emphasized. Instead, the broader economic perspective should be tackled, including the advantages of reduced costs associated with medication errors. This will foster the commitment of the staff while at the same time establish the background for cooperation with the administration. Finally, at this stage, the committee is formed which would be responsible for decision-making. The committee’s main responsibility at this point is to determine the resources and staffing necessary for the assessment phase and secure the permission of the hospital’s management to perform the evaluation.
Once the stakeholders are familiar with the basic premises of lean culture, we may identify the problem. At this stage, it is important to track and log the process of medication prescription and administration. Specifically, the details such as the location of prescription process, routes of document circulation, and the number of involved employees must be logged and analyzed. Ideally, an observation should also be conducted detailing the routes of nursing practitioners engaged in medication prescription and administration. The results can be graphed in the form of spaghetti diagrams for transfer routes and simple tables for required steps.
The results of observations must then be analyzed for the possibility of interruptions, such as non-essential conversations, needless drawbacks caused by non-value-added time, and environmental conditions prone to distracting external factors. The spaghetti diagrams may also reveal unnecessary steps in the process such as the need to travel extra distance or perform an additional activity. Such elements are obviously undesirable since they have a cumulative effect on nurse practitioner’s attention. As a result, they are less concentrated on the task when they arrive at an important decision.
The produced data is then surveyed by the committee, and possible amendments to the process are discussed. The solutions may include the relocation of a certain source of documentation or supplies to the adjacent room to eliminate the need to travel extra distance. If the observations detect frequent interruptions immediately during the prescription process, the allocation of a specific space free of distractors (a room or a quiet zone) could solve the problem.
Finally, if the assessment results imply a positive connection between the number of prescribed medications and the possibility of an error, a checklist could be developed to eliminate the need for NPs to memorize large amounts of information. Importantly, the expected improvements should also be conceived at this stage to create an opportunity for assessment of the intervention. The results of the evaluation, the suggested measures, and the projected outcomes are then communicated to the hospital’s administration. This is important for two reasons. First, it strengthens the ties and ensures coordination between the actions of stakeholders. Second, it allows obtaining permission and support for certain logistical and organizational changes, such as those illustrated above.
Once the change is implemented, the monitoring phase begins, during which the data is collected, processed and compared to the results obtained before the intervention. Aside from the evaluation, it allows to detect shortcomings of the initial plan and adjust them accordingly on the fly. In this way, a seamless, uninterrupted process is maintained which does not disrupt the established nursing routines. The committee at this stage regularly checks the intervention’s success by comparing the results to the set benchmark indicators. At this point, it is important not to overlook the continuous nature of the suggested solution. This means that the established objectives and benchmarks are not an ultimate goal – instead, they need to be perceived as milestones. In case they are not met, the reasons should be determined and proper adjustments made. In the opposite case, new standards can be set according to the capabilities of the team or the newly emerging factors. As a result, the desired level of service can be maintained and the number of errors minimized.
Admittedly, there is no way of predicting even the approximate impact of such intervention. Its flexibility and universality make it dependent on many factors, including the initial conditions of the establishment’s infrastructure, a commitment of nursing staff and its level of resistance to change, and the readiness of the administration to cooperate. Nevertheless, it requires little to no funding since all of the observations and analysis can be performed via simple equipment. Instead, it relies on the participation of the staff, which may, but not necessarily does, require adjustments in schedules. Besides, it does not rely on special training beyond the simple and highly accessible set of events such as lean workshops. Finally, numerous instances of lean culture implementation in healthcare establishments are well-documented and overwhelmingly positive (Steyrer et al., 2013). Thus, the intervention is suitable as a starting point for minimizing medication errors.
Collective Accountability
Individual nurse practitioners are commonly perceived as a final stage in the process of medication delivery since they administer the prescribed drug. This seemingly burdens them with bigger responsibility as they are able to withdraw a faulty prescription. However, the NPs act within a complex and multi-layered system. Such setting introduces uncertainty in the process of determining individual accountability which, in turn, leads to situations where under certain conditions it becomes both possible and tempting for a nurse to assume little to no responsibility for a certain action and act upon possibly faulty instructions (Wachter, 2013).
Such setting can be improved in two ways. First, healthcare establishment in question can review its policies dealing with punishment for errors. Specifically, the attention needs to be focused on punitive measures which discourage reporting of faulty actions. Such measures usually do not have a positive effect on the performance of staff but create conditions where preventable errors are left unreported and on some occasions, unaddressed (Bell, Delbanco, Anderson-Shaw, McDonald, & Gallagher, 2011). Essentially, the policies should be formulated to encourage nurses to report the detected errors and reward them for prevention of possible adverse effects. Second, additional effort must be made to emphasize the importance of teamwork.
This is traditionally achieved by allocating resources for team training initiatives. To further reinforce the effect, the concept of “collective accountability” can be introduced and promoted in the workplace. Admittedly, the latter is not recognized by law, which undermines the desired effect. Nevertheless, after transforming the understanding of accountability as shared by the team rather than narrowed down to a single person, we can expect readiness to accept responsibilities associated with medication errors and, by extension, a decrease in adverse patient outcomes. Simultaneously, the absence of unjust punishment will encourage NPs to report the detected errors which, in turn, will improve our understanding of the issue and increase out monitoring capabilities.
Patient Involvement
At least some of the medication errors which occur in hospitals toady can be prevented through better patient involvement. Both the patients and their carers rarely possess the knowledge required to locate inappropriate prescriptions or dosages. This is mostly due to a reluctance of nurses to involve them into the treatment process. At the same time, a growing body of evidence points to the connection between patient education and improved patient outcomes (Trillingsgaard, Nielsen, Hjøllund, & Lomborg, 2016). Arguably, this element of the intervention is the easiest to implement since it requires no additional resources or serious schedule alterations. Instead, the benefits of patient involvement need to be communicated to the nursing staff along with possible benefits of patient cooperation. Such strategy aligns well with the lean culture and can be easily established within a highly motivated and dedicated community, which makes it a desirable candidate for the expansion of the initial intervention.
Automatization of Medication Prescription
According to the data provided by the Institute of Medicine, at least 25% of medication errors are preventable and can be avoided by implementing computerized provider order entry (CPOE) (Radley et al., 2013). The use of CPOE eliminates several causes of medication errors, with unintelligible handwriting, inappropriate abbreviations, and incorrectly placed decimals being the most obvious ones. Other less evident benefits include automatic notifications about possible adverse effects of certain drugs, harmful interactions and mutually excluding medications, and clinical decision support, all of which contribute to error reduction. A systematic analysis of existing studies conducted by Radley et al. (2013) suggests a 12.5% reduction of medication errors associated with the implementation of CPOE in hospitals, which roughly equates to 17.4 million prevented medication errors.
It is important to note that this intervention is the most controversial from the list. First, as revealed by literature review, the improvement is uneven, with several studies suggesting an increase in errors (Radley et al., 2013). Second, CPOE in its current state is still a developing field, and many of its aspects remain underresearched. Finally, the cost of equipment, reliance on special training and education, and overall novelty of the concept pose serious difficulties to securing the cooperation of the administration in adopting the intervention, let alone the guarantees of its success. Nevertheless, it creates a possibility of resolving several causes with a single intervention and thus must be considered as one of the possible solutions.
Annotated Bibliography
James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128.
The persistence of preventable medical errors is a doubtless fact. However, when it comes to data, many researchers tend to cite a 98,000 deaths per year figure, which is obsolete. To update the data, a revision was undertaken by the authors of the study. A weighted average of the results of four limited studies based on the Global Trigger Tool produced a much higher lower number of 210,000 deaths. Importantly, the updated data characterizes a lower limit which does not account for several limitations, with an estimated true number nearing 400,000. These results emphasize the necessity of urgent intervention.
Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association, 20(3), 470-476.
Computerized provider order entry (CPOE) is one of the most evident contributions to the solution of the medication errors issue. However, the exact effect of CPOE is still debatable. A study by Bradshaw aims at estimating the possible reduction of medication errors based on the existing degree of CPOE adoption and the decrease in the likelihood of error. The findings produce an estimated 12.5% improvement. According to the author, the suggested rate allows us to embrace CPOE adoption and pursue changes in healthcare policies in favor of its nation-wide implementation.
Steyrer, J., Schiffinger, M., Huber, C., Valentin, A., & Strunk, G. (2013). Attitude is everything?: The impact of workload, safety climate, and safety tools on medical errors: A study of intensive care units. Health Care Management Review, 38(4), 306-316.
Safety culture and safety climate are often cited in literature as viable means of decreasing medication errors and generally improving patient outcomes. However, their exact weight is not identified conclusively. A cross-sectional study assessed the effect of safety culture implementation and compared it to the effect of increased production pressure. Predictably, the results indicated a disruptive effect of increased pressure on patient safety and an opposite effect of safety culture introduction. A disaggregation of safety culture means indicates a strong effect of safety climate and a comparatively weak one of formal procedures and policies. The findings allow us to prioritize the tools in safety culture implementation process.
References
Bell, S. K., Delbanco, T., Anderson-Shaw, L., McDonald, T. B., & Gallagher, T. H. (2011). Accountability for medical error: moving beyond blame to advocacy. Chest Journal, 140(2), 519-526.
Lehnbom, E., Oliver, K., Baysari, M., & Westbrook, J. (2013). Evidence briefings on interventions to improve medication safety. Centre for Health Systems and Safety Research, 1(2), 1-4.
Trillingsgaard, C., Nielsen, B. K., Hjøllund, N. H., & Lomborg, K. (2016). Use of patient-reported outcomes in outpatient settings as a means of patient involvement and self-management support–a qualitative study of the patient perspective. European Journal for Person Centered Healthcare, 4(2), 359-367.
Wachter, R. M. (2013). Personal accountability in healthcare: searching for the right balance. BMJ Quality & Safety, 22(2), 176-180.