Medication Errors, Term Paper Example

Although I have not had extensive clinical experience, one of the main quality improvement issues in my previous clinical environment was medication errors.  Indeed, I experienced a number of incidents including medication errors at “X” hospital that had an adverse impact, including prolonged illness, hallucinations, and even death.  The sources of medication errors were plentiful: poor doctor’s handwriting, incomplete knowledge of drug impact, and just plan laziness.  Although I only worked in one department, and thus cannot generalize my experience to the entire hospital, a number of improvements could be made.  First, nurse staffing levels could be increased; although this is somewhat of a controversial recommendation, a number of errors were made by nurses who did not either have the time or were simply exhausted.  Second, there could be greater implementation of technology, particularly regarding medications and appropriate dosage. At the hospital I worked at there was a low level of information technology used; this could certainly be improved.  Finally, there could be a systematic review undertaken by the hospital to understand in greater detail why medication errors happen and a plan devised to decrease the total number of errors.

Although technology, and particularly electronic patient records (EPR), has been held out as a “silver bullet” to cure a number of severe ills in the health system, there needs to be a sober assessment of what technology can accomplish.  Overall, technology would be helpful in addressing many causes of medication errors, including poor handwriting and substandard understanding of drugs.  Technology likely has to be part of any solution reducing the number of medication errors in a clinical setting.

The problem of implementing technology is closely related to what data is available to analyze the current problem.  While medication errors are reported to the director of nursing, who likely has a more complete understanding of the data.  There are two problems with the current system: 1) All the data is in the hands of supervisors which do not distribute it  or go over it with the nurses; 2) While the data might be able to provide one side of the story, there also need to be qualitative analysis in order to understand the background of the error.  While technology could play a key role in this process, it would need to be accompanied with a clinical culture of greater transparency and discussion regarding the data.

I have chosen the Agency for Healthcare Research and Quality (AHRQ)  (http://www.ahrq.gov/). I chose the AHRQ for several reasons: 1) The AHRQ is the main federal body tasked with the job to monitor and improve the overall quality of health care- it is also tasked with allocating grants to accomplish that mention; 2) The agency plays a key role in proposing and thinking about innovating solutions to improve health quality including issues such as medication errors.

Overall, the credentials of the AHRQ are unrivaled as a part of the Department of Health and Human Services., a federal agency tasked with improving quality in health care delivery. Indeed, because of the AHRQ’s status as a thought leader in the field, doctors, administrators, and nurses know the organization has credibility and uses evidence-based recommendations on its website.  The AHRQ does a sufficient job of allowing users to facilitate information and its source on the web site; in addition to listing officials or researchers that are in charge of maintaining the page, there are numerous citations used when advocating policies or recommending certain policy actions.  Due to recent actions taken by the government to improve transparency of websites, particularly regarding the provision of health care information, pages on the web site are marked with individuals responsible for content.  In addition to a high level of transparency, there is a wide breadth of information on the site that is not likely available on any other web sites.  Indeed, I did a quick comparison on the issue of medication errors with other web sites dedicated to health care quality, and found that the information was less thorough and more general than that provided on AHRQ’s homepage. This is likely because the AHRQ aims to be the thought leader in a wide range of quality improvement topics, especially to help drive policy discussions and perhaps smaller health care institutions that do not have adequate resources to research best practices.  Indeed, looking at the page provided on the web site, there is no mistake that the AHRQ is one of the foremost leaders in the field on this topic.

Regarding the issue of updating information, there is a date included on all web pages indicating the last time it was updated- this is particularly important when addressing treatments or reviews of evidenced-based practices that might change with the  release of new research,.  Overall, at least in my opinion, there is less of a concern with a federal agency regarding issues of bias or sponsorship; indeed, the government should have fewer conflicts of interest than a private organization that aimed to provide a similar wealth of information.  If not, federal laws usually mandate that potential conflicts of interest be publicized.

The one downside of the AHRQ website is the large amounts of information and difficulty in navigating to a particular topic.  Indeed, although the web site covers literally every possible medical topic available, the main content web page is nearly impossible to navigate with letters ranging from A-Z draped over the top of the home page, and additional topics addressed on the side of the page. There is no perceptible organization to the web site; the Agency could do a better job of organizing the information so that it might be accessed with people who are not necessarily researchers or hospital administrators.   The AHRQ makes it clear on the web site that online resources are meant for everyone from medical professionals to lay individuals.  However, there is a problem in providing information to such a wide range of stakeholders:  By trying to satisfy such a wide range of users, it is not exactly clear how users select what information is useful for them without guidance from the website.  At some level, individuals without administrative, medical or epidemiological training likely self-select out of more complex research articles and read more general articles on the topic. Another important feature of the AHRQ site is disclaimers.  Because the AHRQ is a government agency, with particular sensitivities about providing biased or incomplete information, the website has numerous disclaimers explaining the nature of information presented and how the information should be interpreted.  As a federal agency, the site is accredited under the DHS umbrella.  DHS is the main bureaucracy in the federal government making decisions on behalf of Americans regarding the design and implementation of health care in the US.  Finally, the site clearly spells out the privacy policies for information contained on the site.

Overall, the AHRQ has substantial influence on how medication errors are dealt with at larger and smaller health providers.  At a federal level, the AHRQ is one of the main advisors to the federal government regarding implementing measures that would be incumbent on all hospitals and health care organizations.  At the local level, the AHRQ is part and parcel of teams of regulators that make sure existing regulations are followed. At the same time, the input used for implementing and feedback regarding existing regulations may emerge through AHRQ processes.

AHRQ adopts a number of measures in order to promulgate policy on medication errors. First, the AHRQ has a page (http://www.ahrq.gov/consumer/20tips.htm  dedicated to helping health care provider organizations understand the issue of medication errors more in-depth. There are a number of reasons and proposals to help reduce the number of medication errors in clinical settings. In particular, the AHRQ identifies some of the main causal mechanisms that leads to patient errors: 1) physician’s lack of knowledge about the drug or about the patient for whom it was prescribed; 2) failures in disseminating pharmaceutical information, in checking drug doses  and patient identities, and making patient information available were a majority of the errors.  AHRQ research also shows that 75% of cases involving medication errors are at the systemic level, rather than simply being an individual error not related to general practices.

The AHRQ proposes a number of solutions to deal with the trenchant problem of medication errors. First, the computerization of medical records would be a solid first step in reducing the number of medical errors; such technology would help systematize prescriptions and give clear guidance regarding what drug should be taken at what dosage. The second main solution proposed by the AHRQ is standard protocols in how medication is given. Third, and perhaps surprisingly, is forming robust, institution-wide, quality improvement measures that increase transparency and encourage discussion regarding these issues. There is a main difference in the analysis proposed by the AHRQ is the emphasis on systemic errors, versus one-off errors that often times attributed to individuals rather than the system.  In my previous analysis, I spoke of medical errors as belonging to the latter rather than the former.  There should be a greater emphasis on viewing medication errors as part of an organizational structure.

Brady et al. (2009) perform a systematic literature review to uncover the main causal factors for medication errors. Overall, the authors identify five main factors: 1) Reconciliation errors- errors related to the misunderstanding or misreading of medical history or orders; 2) Drug distribution- essentially, the correct drugs are not in the specified area; 3) Deviation from procedures- deviation from established clinical protocols; 4) Quality of prescriptions- ineffective written communication; 5) Knowledge and medication errors- improper diagnosis of symptoms (Brady, Malone & Fleming, 2009).  In addition to including a general literature review of causes related to medication errors, I wanted to include an article that looks at medication errors in a particular practice.  Handler et al. (2007) conducted a study analyzing medication errors in a nursing home setting: They surveyed practitioners from across the spectrum including nurses, pharmacists and administrators. Overall, the survey found that organizational factors played the largest role in medication error followed by individual factors. Both articles point to similar areas where improvement; although the second article organizes them into two different categories (organizational and individual) they largely mirror the factors found in the literature review, although the first article was examining medication errors across different clinical settings.  For example, reconciliation errors, drug distribution, and knowledge and medication errors are clearly systematic in nature being connected to how the provider organization prescribes and validates drugs, as well as training initiatives for nurses.   This evidence leads me to believe that my proposal needs to focus more on preventing medication errors from the top-down rather than the bottom-up- although this is more a question of ratio as both approaches need to be taken.  Overall, I learned a number of important lessons from this intellectual exercise.   First, in understanding the importance and preventative strategies behind medication errors, the examination of systemic factors is paramount.  At first glance, one may see a nurse or doctor make a medication error, and posit that the mistake is his/her hers alone and not part of a more general system.  After looking at the AHRQ website and articles, however, there is a clear pattern to how a breakdown in the provision of health care (at all levels) is the main causal mechanism behind medication errors.  Second, and perhaps more commonsensical, is that different strategies must be implemented in different clinical environments where medical errors are prevalent.  For example, although most medical errors can be traced to systemic errors, every health care institution and department have different ways of dealing with patients. That is, the milieu for preventing medical errors is much different in a nursing home, largely due to the volume of prescriptions and the stakes if wrong medication is taken.  Indeed, although risk exists across the clinical spectrum for medication errors, prevention efforts and analysis must also be   grounded in the particular environment where they occur (e.g., nursing home, pediatrics, etc.).  Third, I learned more about the AHRQ and its role as part of the Department for Health and Human Services.  That is, the AHRQ not only plays a main role as one of the main funders of health care quality in the federal government, but also as an influential shaper of the health quality debate at the federal level.

I think there are a number of applications for my own practice. First, I will pay more attention in the future to how and why medication errors across different departments in the hospital. I will not only pay more attention to the type of error made, but also, perhaps trying to connect that errors to structural deficiencies in what may be causing this error to occur.  That is, I have a more general understanding of the link between medication errors and their origin.

If I were to present my humble proposal to change the current system, I would emphasize the following three points: 1) A preponderance of existing health services research shows that medication errors is linked to health care delivery- depending on the scope of the organization, different measures are called for; 2) Medication errors can be prevented through systematic planning and reform.  Indeed, while the improvement with some problems may be marginal and difficult to achieve, medication errors provides an opportunity to pick “low-hanging” fruit that has a palpable impact on health outcomes. 3) Improvements for medication errors, particularly at the system level, have a positive knock-on effect to take on other problems that will help to increase the quality of care. Although one might think of quality issues affecting different individuals and different areas, the ability to reduce medication errors will have knock-off effects.  This is particularly true as hospitals begin to implement technology systems that will also have benefit in dealing with other problems.

My overall estimation is the best practice knowledge of the average bedside nurse is not robust.  Although bedside nurses do have knowledge of doing the right thing in a  particular situation, I am not sure that all practices are evidenced-based and linked to a higher goal .

I think there are probably two main things I can do to improve my own professional knowledge and best practice within the nursing peer group. First, ask question: That does not mean only asking what to do, but also asking why someone does it a certain way rather than another way. Second, promote discussion and research of questions that will help to increase the overall knowledge level of the group. I think our practice group needs to promote a more inquisitive, evidence-based practice that will help drive better results.

References

Brady, A.M., Malone, A.M. & Fleming, A. (2009).  A literature review of the individual and systems factors that contribute to medication errors in nursing practices. Journal of Nursing Management. 17(6), 679-697.

Handler, S.M., Perera, S., Olshansky, E.F., Studenski, S.A.,Nace, D.A., Fridsma, D.B. (2007). Identifying modifiable barriers to medication error reporting in the nursing home setting.

Journal of the American Medical Directors Association. 8(568), 568-574.