Introduction
There are a variety of processes involved in the healthcare system, which makes the effective functioning of this sphere highly complex. Healthcare professionals care for patients in different ways, but one thing is common to all these duties: the patient is at the core of the process. Another vital requirement for successful treatment and care is effective communication at all levels.
Problems can occur in diverse dimensions, including procedures, outcomes, and structure. In any case, it is crucial to identify the issue and develop a plan to resolve it, achieving the most beneficial outcome for the patient. One of the most frequent problems in the health care system is medication errors. Due to the severity of the potential consequences of drug mismanagement, this question requires serious consideration and calls for a plan of quality improvement.
Problem Identification
The identified problem is medication errors and their effects on patients and the healthcare system as a whole. The selected issue is pertinent to both the process and the outcomes, as medications are an inseparable part of the treatment process and also affect care outcomes. The issue is rather serious, as medication errors can occur at various stages: during prescription or preparation, or even during distribution or consumption (The U.S. Food and Drug Administration [FDA], 2019).
The FDA (2019) admits receiving as many as 100,000 reports related to suspected medication errors annually. The most dangerous and harmful effects of medication errors include hospitalization, disability, congenital disabilities, and life-threatening situations. Above all, such mistakes can lead to deaths, with 7,000 to 9,000 cases recorded yearly in the USA alone (Tariq et al., 2023). Therefore, there is a pressing need to mitigate this problem to improve patient safety and the quality of care.
Quality Improvement Methodology
Numerous improvement methodologies can be employed, including total quality management, Six Sigma, root cause analysis, and others. Given the selected issue, the plan-do-study-act (PDSA) methodology seems most suitable. The approach encompasses four phases, the first one being planning (Hybarger et al., n.d.).
During this stage, the objective of the quality improvement is set, along with the predictions of why the change is needed and how it can be managed. The decision on the division of roles and responsibilities, as well as setting the milestones and timeframes, is also included in this phase. Additionally, the planning step involves deciding where the strategy will be implemented and what will be measured to assess its impact (Hughes, 2008). The second stage involves implementing the plan, documenting successes and problems, noting unexpected occurrences, and conducting an initial analysis of the data (Hybarger et al., n.d.). These two stages of the PDSA methodology are the most crucial.
However, the subsequent two phases are no less critical, as they focus on analyzing the quality improvement initiative and predicting future actions. The study phase involves a thorough analysis of all collected data to compare them with the anticipated results (Hybarger et al., n.d.). Additionally, this step presupposes a summary of what has been learned or achieved in the process. Finally, the fourth phase of the PDSA methodology involves deciding whether to implement the change or whether another cycle is necessary (Hughes, 2008). The chosen approach is thus highly relevant to healthcare issues, as it provides an opportunity to analyze the quality improvement approach and carefully evaluate its effectiveness.
Key Stakeholders
The identification and engagement of stakeholders is a crucial part of any improvement or change process, as they include the individuals responsible for planning, implementing, and evaluating the endeavor as a whole. Moreover, stakeholders include those accountable for managing the initiative. Therefore, the current process will involve stakeholders such as the healthcare organization or department manager, healthcare personnel directly working with patients, information technology professionals, quality improvement specialists, patients, and an ethics committee.
The manager will be responsible for the planning of the initiative. Healthcare providers will be involved in the planning and implementation phases. In the second phase, they will be facilitated by information technology and quality improvement specialists. The latter will also participate in the third phase, when results will be analyzed.
Patients and their families will be part of the plan during the design and study phases. At first, their feedback on the ongoing processes will be collected. Next, their impressions of the changes will be collected to obtain relevant data on the initiative’s impact. Finally, the ethics committee’s role will be evident throughout all phases of the plan to ensure that the medication error elimination process is implemented with patient safety in mind. Each stakeholder group is essential to the project, as dynamic collaboration among them will lead to comprehensive implementation.
The Root Cause of the Problem
Medication errors have multiple root causes, combining human factors, organizational culture issues, and system failures. The most common cause of the identified problem is a lack of communication among healthcare professionals, leading to misinterpretations of medication orders or prescriptions. When there is insufficient communication between those who prescribe, sell, and distribute drugs, errors are more likely to occur.
Furthermore, the lack of training and fatigue can also contribute to the issue. System-related root causes include complex systems for distributing medicine, technological issues, and understaffing. At the organizational level, factors such as a blame culture and the lack of a reporting system significantly increase the likelihood of mistakes.
Planned Improvement Steps
The Planning Phase
During this step, the team of specialists will be assembled. The team will include the manager, healthcare personnel, technology and quality improvement specialists, and the ethics committee representatives. Upon assembling the team, a detailed plan of the initiative will be drawn, including the responsibilities of all stakeholders and the timeline. The analysis of the current approach and the comparison between the current and the suggested one will be carried out at this point. The improvement strategy to be tested in the process is the introduction of a clinical decision support system (CDSS) to minimize and prevent medication errors.
The Doing Phase
During this phase, the CDSS will be installed in the organization, and healthcare providers will receive relevant training and support from the technology and quality improvement specialists. A CDSS has been reported as a viable option for minimizing medication errors (Corny et al., 2020). By introducing this change within the organization, the team will be able to monitor their actions, promptly report any misunderstandings, and track all medications. At this point, patients will also be involved as feedback will be collected from them.
The Study Phase
This stage is the most crucial for analyzing the obtained data. The manager, technology specialists, ethics committee, and healthcare team will all work together to study the initiative’s outcomes. Data from pre- and post-initiative medication error reports will be compared and carefully analyzed to determine the effectiveness of the change. Patient satisfaction will also be evaluated and compared to previous findings.
The Act Phase
The final stage of the improvement initiative involves deciding on the ultimate effect and the future actions related to it. It is expected that the introduced innovation will improve the quality of care and safety of patients. In this case, the CDSS will be incorporated into the organization’s work regularly. However, if the results are not sufficient to be considered positive, a new approach will have to be developed.
Evaluation of the Improvement Initiative’s Effectiveness
Assessment of success will begin during the final stage of the PDSA process. The evaluation will involve a survey among the healthcare team and patients. Also, the ethics committee will have its say in the process by determining whether all measures have been adequately taken. Most importantly, the indicators of medication error incidence and prevalence will serve as the point of success. If the number of errors is significantly lower than in previous reports, the initiative will be viewed as effective.
Conclusion
Quality improvement is an aspect of healthcare organizations’ work that cannot be overlooked. Medication errors are among the most severe contributors to harmful outcomes, so all healthcare organizations must take steps to eliminate them. However, it is essential to remember that not all initiatives for increasing quality are successful. Apart from suggesting and testing improvement plans, it is also crucial to carefully analyze the results and propose alternative solutions if the initial plan does not unfold as expected.
References
Corny, J., Rajkumar, A., Martin, O., Dode, X., Lajonchère, J.-P., Billuart, O., Bézie, Y., & Buronfosse, A. (2020). A machine learning–based clinical decision support system to identify prescriptions with a high risk of medication error. Journal of the American Medical Informatics Association, 27(11), 1688-1694.
Hughes, R. G. (2008). Tools and strategies for quality improvement and patient safety. In R. G. Hughes (Ed.)., Patient safety and quality: An evidence-based handbook for nurses (Vol. 3, pp. 3-1–3-39.). Agency for Healthcare Research and Quality.
Hybarger, K., Steigmeyer, C., Lee, B., & Woolley, L. (n.d.). Quality improvement process using plan, do, study, act (PDSA) – Planning for action.
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2023). Medication dispensing errors and prevention. StatPearls.
U.S. Food & Drug Administration. (2019). Working to reduce medication errors.