Planning for Change: A leader’s vision

Executive Summary, Outcome Measures for Medical Errors

Medication errors are prevalent in the healthcare sector, and they pose a potent threat to the quality of care provided to patients. According to Márquez-Hernández (2019), 70% of nurses have made a medication error in the course of their practice. Medication errors may lead to severe injury to patients, longer hospitalization spans, new conditions such as skin rashes and itching or disability. Gorgich et al. (2016) asserted that 30% of patients impacted by medical errors die or develop disabilities lasting over six months. The health conditions caused by medication are a financial burden because they lead to increased medical costs; in the United States, expenses incurred due to medication errors are approximately $6.5 billion (Gorgich et al., 2016).

In the last six months in our facility, there has been an increase in medication errors with three incidents reported. In the first one; a nurse injected a patient with Penicillin, without inquiring if they were allergic to Penicillin, and it led to adverse events including excessing vomiting and diarrhea. In the second one, a patient was wrongly prescribed medication for high blood pressure, yet he had been diagnosed with viral gastroenteritis, therefore, his condition was exacerbated leading to readmission. In the third one, an admitted patient with chronic obstructive pulmonary disease (COPD) was administered extra doses of prednisone 60 mg and methadone dose of 80 mg during the night shift leading to the development of new symptoms. The cases are alarming because they implied that patient safety in the facility was lacking and they hindered the realization of quality medical care in the facility. Therefore, interventions are required to prevent further medication errors from occurring that would damage the facility’s reputation. This executive summary describes the outcome measures to be employed in change implementation efforts and the role of leadership in addressing medication errors in the healthcare organization.

Executive Summary on the Gap

The findings from the undertaken safety gap analysis showed that there is an urgent need to address the prevalent medical errors in the organization. Therefore, investigations on the reported incidents were conducted to determine the factors that led to their occurrence. In the first incident, the nurse did not conduct a thorough assessment on the patient as he believed all the information was in the patient’s file but it was found out that it had not been updated for the three years. Therefore, the information on his allergies was missing and the nurse was held accountable for the medication error for failing to conduct his due diligence. In the second incident, the nurse was preoccupied when handing out the prescriptions and failed to notice that he had given a patient the wrong one. Again, the nurse was held accountable for the error and a new one nurse was appointed to care for the patient following readmission. In the third incidence, two different night shift nurses gave a COPD patient, the same medications within two hours, yet the physician had instructed that they were to be administered within fours. The second nurse had failed to look at the patient’s chart before administering the medication and only noticed that the dose had been administered when documenting her dose. The patient developed increased chest pains and difficulty in breathing but after vomiting was induced, the symptoms disappeared. The second nurse was held accountable for the errors because she failed to read the patient’s chart before administering medication.

The safety gap analysis in the healthcare institution showed that the medication errors resulted in increased hospitalization costs, increased length of stays, and distrust from the patients. Fortunately, the three incidents did not cause any disabilities and the three patients did not escalate the medication errors to litigation. Still, the safety gap analysis highlighted a significant decrease in healthcare quality in the facility that needs to be addressed before it leads to irreversible damage to patients and the hospital.

Quality and Safety Outcomes

Quality and safety outcomes refer to the impact that a particular health intervention will have on the healthcare quality provided to patients. In this section, three interventions related to the described incidents will be provided and their expected outcomes to the health of patients.

Implementation of Patient Portals

In the first incident, the nurse administered a medication the patient was allergic to, and on further investigation, it was identified that the patient’s health information had not been updated for three years. To address the problem, the facility can implement patient portals; it is a website that enables patients to access their health information and update it regularly. Also, they can schedule appointments, engage their healthcare providers, request prescription refills, analyze laboratory results and pay medical bills (Sieck, Hefner & McAlearney, 2018). Additionally, healthcare practitioners can access the updated information at any time, thus, ensuring accurate diagnosis and medication administration based on the patient’s information. Therefore, it is expected that it will lead to reduced medication errors that occur because of a lack of sufficient patient health information. However, still, nurses are required to fully assess a patient before administering any medication to prevent any adverse effects.

Double-checking Policy

While double-checking should be instinctive for every healthcare practitioner, based on the second incident, it showed that not every health provider double checks medication prescriptions before giving them to patients. The physician, gave a viral gastroenteritis patient, a prescription for high blood pressure leading to exacerbation of their condition. The error can be understandable when the doctor and nurse are treating an increased number of patients, nonetheless, it should not occur because it can have adverse effects. To ensure that it does not occur again, a double-checking policy should be enacted in the facility, it should be detailed including ways that the process should be conducted. For instance, a nurse or another physician, familiar with the patient’s condition should be present when medication prescriptions are written to verify the medication order including dose, patient identification, dose calculation, and patient weight (Westbrook, et al. 2021). The intervention is expected to help prevent medication errors based on prescriptions.

Staff education

In the third incident, a COPD patient was administered a double dose after two night shift nurses administered the same medications within two hours instead of four as instructed by the physician. To avoid such errors, the staff should be educated on how they occur and prevented. The staff education can be conducted by a third party; healthcare agencies such as the Joint Commission conduct safety education in hospitals. The intervention is expected to make the staff aware of such errors and be keen to avoid them, thus, ensuring patient safety. According to Chaghari et al. (2017), staff education improves the nurses’ competency and professional skills leading to the provision of quality care to patients.

Role of the Quality Outcome Measures

The interventions are expected to improve the quality of care administered to patients and prevent medication errors. By improving the quality of care, patient satisfaction will increase and they are likely to recommend the facility to other people, thus, enhancing the reputation of the hospital. A hospital with a good reputation is likely to witness an increased number of patient visits and profits. According to Akinleye et al. (2019), public reporting based on the quality of services has the potential to influence the reputation of a hospital, patients’ opinions, and demand for its healthcare services as well as market share. Improved care services will help enhance patients’ relationships with nurses and physicians, which is significant because it enhances trust and loyalty. Further, the prevention of medical errors in the hospital implies that the hospital is committed to patient safety, which will also significantly improve its reputation. Therefore, executive leaders and healthcare practitioners need to enforce the interventions to facilitate improved quality of services.

Role of Nursing Leaders in Supporting Quality Outcome Measures

Nursing leaders should be ready to adopt the interventions into the clinical practice and lead by example. The following steps should be taken to ensure the adoption process is successful; it is essential first to communicate the transition to other nurses. For instance, with the implementation of patient portals, the nursing leader can hold a meeting to inform the staff of the website and its purpose in preventing medication errors. Also, the nurse leader can organize training, where the staff is taught how to operate the patient portal including how to retrieve the required health information and communicate with patients. The move will help ensure a seamless adoption of the patient portal in the facility.

With the double-checking policy, the nurse leader can help physicians ensure that the prescriptions issued to patients are correct. They can scrutinize each detail on the prescription ensuring that the medication will not lead to adverse effects, thus, promoting patient safety. In the case of staff education, the nurse leader can organize the whole process including selecting who will conduct it and writing the schedules to ensure that all the staff attend it without disrupting services at the hospital. By taking such actions, the nurse leader is likely to inspire change from the staff that could have a positive impact on the care provided to patients and the facility in the long run.

Conclusion

Medication errors adversely impact the quality of medical care provided in a hospital, therefore, it is essential to develop interventions for quality measuring outcomes in nursing practice, aiming to improve the quality of medical care rendered to the patients. Based on the safety gap analysis conducted in the facility, the issues identified were; administration of medication to patients that they were allergic to, issuance of wrong medication, and overdose. As such, the interventions suggested are; implementation of the patient portal, enactment of a double-checking policy, and nursing education, respectively. The interventions are expected to prevent medication errors, improved quality care, and patient safety that will positively impact the reputation of the hospital leading to increased demand for its services. Nursing leaders have a significant role to play to ensure the quality outcome measures interventions are adopted such as effectively communicating the new changes, organizing training, and leading by example.

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