Medication Errors: Case Study Analyses, Essay Example

A recent  Joint Commission inspection of the hospital found a number of problems. For the purposes of this case study, the focus is on issues related to medication errors, and the fact that these errors were not being reported accurately and completely. As the VP of nursing services for the hospital, Frances Ballentine, RN, MSN, was ultimately responsible for dealing with the problem and finding solutions to solve it. Ballentine was already aware that there was a problem, as she sometimes did not receive reports in a timely fashion and also suspected that some incidents of medication error were unreported. It was not until the report from the joint commission, however, that Ballentine began to realize the scope and significance of the problem.

Ballentine began her investigation into the situation by working on her own to develop an understanding of the issues she had to face. Her first step was to determine whether there was a process in place for reporting medication errors, and she quickly found out that there were written process and procedure manuals available for each floor. With this information, Ballentine was able to determine that the problem was not a lack of established procedures; the problem was that the procedures were not being appliedconsistently and effectively. Ballentine’s initial investigation and observation led her to estimate that somewhere between 20-30% of medication errors were either not reported correctly or were not reported at all. This realization led Ballentine to take the next step in her investigation by enlisting the help of other people.

The first person Ballentine went to was Ally Ray, the director of Quality Improvement. The decision was quickly made that a team should be assembled to analyze the situation and to make determinations about the current reporting procedures and processes to see where improvements could be made. Ray requested some additional information from Ballentine so that she could develop a proposal for a Medication Errors Quality Improvement MEQI) project, and this project was quickly approved by the hospital. The team assembled for this project included the representatives from each of the six hospital units and from the pharmacy, with the idea in mind that this would help determine where problems were happening. The team members were trained on basic quality measures and principles using the Total Quality Management/Continuous Quality Improvement (TQM/CQI) model.

In order to ensure that the process of assessing and responding to the problems was successful, the team adopted the FOCUS-PDCA framework. This two-component approach begins with finding a process to improve, organizing a team that understands how the process is supposed to work, clarifying the knowledge the team members have about the process, understanding the reasons why the process is not always correctly followed, and selecting a strategy for improving the process on a continuous basis. The second component, PDCA, is a system for assessing and monitoring the continuous-improvement cycle, using a Plan-Do-Check-Act approach. Using this framework, the team held a series of meetings to focus on each stage of the FOCUS-PDCA model. Because the problem was serious, it was not possible to resolve the related issues overnight, as it was first necessary to pinpoint exactly where the problems were happening before they could be fixed. Among the first steps taken was having each team representative develop a cause-and-effect chart using a “fishbone diagram” to help determine why errors were unreported or not reported quickly enough.

It soon became clear that there were a number of specific issues that seemed to be at the root of the problem. Among these issues were concerns that the policies and procedures were vague, and that nurses did not understand how to follow them correctly. Although Ballentine had determined early in her investigation that the necessary manuals and forms were available, such resources would be useless if the nurses were not sure how to use them correctly. Of all the issues identified, the one that received the most attention from the team representatives was that the policies were simply too vague. While this realization showed that there was a serious problem, it also helped the team begin to narrow their focus and move towards implementing solutions to the problem.

With some of the most significant issues and problems identified, the team was able to begin developing specific plans for dealing with those problems. Because the policies were considered to be too vague the first step in planning the solution was to revise the policies to make them clearer. Along with the revised policies, some members of the team were assigned the task of developing an online training program so the nurses could become familiar with the revised policies and understand how to put them into action. The revision of the policies also included a revision of the medication error reporting forms, so that all three components (clearer policies, effective training, and effective procedures) were coordinated.

Once these components were in place, it was time to “Do” the work of making them a part of the daily routine for the nurses. For this stage of the process, the individual team representatives met with their staff members to coordinate the process of implanting the new procedures. This process of implementation took one month, during which hands-on oversight and coordinated online training were used together to reinforce each other. The QI team established a target goal of having 95% of medication errors reported correctly and on time. The overall rate of correct reporting before the improvement process began was only 66%, so the target of 95% was clearly challenging. In the initial month following the initial implementation of the QI processes, the “Checks” showed that the overall rate rose from 66% to 72% while also revealing that some units and shifst were showing lower rates than others. The overall improvement showed that the QI processes were having some effect, but it was also clear that more improvements had to be made.

Subsequent monthly checks of the data showed that the reporting rate rose again to 87% overall, while also revealing that the same problem units were not improving at the same rate as the others. This determination made it possible for the QI team to further refine their focus to concentrate on these problem units and shits. The weekend shift in particular was lagging behind on reporting rates. With these issue in mind, the CEO of the hospital was called in to speak directly with the unit leaders to reinforce the seriousness and importance of following the new training and procedures. By the end of December, four months after training and implementation of the new procedures was put in place, the overall reporting rate had exceeded the target goal and reached 96% The weekend shift in particular still lagged behind somewhat, but significant improvements had been seen there and through the hospital.

Conclusion and Analysis

A thorough review of this case demonstrates that there were several issues and factors that combined to keep the error reporting rate so low before the QI process was implemented. Although these issues could be found in several levels of the organization, the problem began with the leadership of Frances Ballentine. Even before the Joint Commission issues its report, Ballentine was aware there was a problem with error reporting, yet she was not doing anything on er own to bring about improvements. The same could be said of the leadership of the individual units, as they were not actively engaged in making improvements. This failure of leadership led to a lack of motivation among the nurses, many of whom did not follow the procedures because they simply did not understand the. Without adequate leadership, these nurses had no motivation to make any improvements.
Ballentine must be credited with improving her own leadership approach, which had the effect of prompting the unit leaders to implementing improvements as well. The information in this case study does seem to show, however, that the nurses were not provided with new motivations beyond simply being required to undergo training and to implement new procedures. When some units did not improve quickly enough, they received negative reinforcement from the CEO for their inadequate response. While the overall reporting rate did eventually reach satisfactory levels, such improvements might have happened more quickly if more effective and specific motivational strategies had been applied. Overall, the QI process was clearly successful, but in the long run it will be the responsibility of hospital leadership to develop and implement strong, positive motivational strategies.