Insufficient Staffing and Medication Errors - Essay Example

?Project Objectives: In order to ensure patient safety, it is necessary to identify the frequency where nurses commit medication errors in relation to short staffing. This project aims to develop a strategy in which the health care system would be able to decrease the prevalence of medication errors dues to short staffing of health care providers, such as nurses. Specifically, the objectives of this project are: 1. To correlate staffing ratios to medication errors 2. To educate staff on how to prevent medication errors 3. To learn how to report a medication error 4. To identify common medication errors due to short staffing Project Description: Patient safety and well-being is the primary purpose of health care systems. Understanding the different factors affecting health care delivery to the patients should be analyzed in order to make sure its objectives are attained. One of the issues that healthcare systems should address in order to optimize its role in delivering quality health care to its patients is medication error. Medication error is any preventable event that may cause or lead to inappropriate use of harm to a patient while medication is in control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures and system including prescribing, order communication, administration, education, monitoring, and use. According to various studies concerning errors in patient medications, there are around 7,000 to 7,400 people in the United States who dies due to such form of negligence. Specifically in New York, there is approximately 1,400 people die every year or twenty percent of medical injuries are due to medication errors. Lawsuits have been filed across the United States health care system as a result of medication errors, which exposed the patients into dangerous situations that eventually cause the death of some patients. According to the National Law Journal, out of the 13 largest medical negligence lawsuits in the US in 2002, seven of these were in New York alone. The number of deaths from medication errors in the US per year is at least one death every day. In addition, the Center for Drug Evaluation and Research found that a total of 1.3 million people are injured because of medication errors. Types of Medication errors Medication errors occur in different ways and at any degree. Medical negligence of this type may be made by any health care practitioner, from the nursing staff to the attending physicians. One type of medication error may be a misdiagnosis of a patient’s illness identified as a diagnostic error. A mistake as complicated as this, may result to more serious problems when made. Misdiagnosis could result to recommending an incorrect choice of therapy to the patient that would further injure them. Failure to use an indicated diagnostic test is also a result of diagnostic error that may cause a patient’s illness to become worse and very serious. Test results may also be misinterpreted due to an error in diagnosis. Patients suffer the consequences of not being able to get the right treatment to their illnesses when such diagnostic error happens. In addition, when patients are misdiagnosed, medical staff may not be able to correctly handle abnormal situations that are brought about by the patient’s illness or disease. Equipment failure is another form of medication error that is classified under this category. Some examples of this are dead batteries in defibrillators and easily dislodged or bumped valves of intravenous pumps. When such conditions are unnoticed, patients may have increased doses of medication over a short period of time that may be too dangerous, worse, fatal to the. Physicians are not spared in committing medication errors as well. The same thing goes with the nurses. Their roles require them to be in close contact with the patients. While physicians prescribe the medications or recommend the proper treatment necessary for the patients, the nurses are those who implement them. Giving the patients the wrong volume or dosage of medication is one of the medication errors that is common among nurse and physicians. Blood transfusion-related injuries are also identified as other types of medication error, specifically when the patients are given incorrect blood type. It is a given fact that suck mistakes may be fatal for the patients. Misinterpretation of other medical orders is yet another medication error in the health care facility that is commonly identified. An example of this error would be failing to give a patient a salt-free meal, as ordered by a physician. Several factors cause health care providers to commit medication errors. This project looks at staffing of nurses as one of the essential factors that may affect the prevalence of medication errors against the patients of a health care facility. Nurse staffing refers to the ratio of patients in a particular unit. Generally, one nurse can be responsible for the care of between one until eight patients at a time. There is no standard formula to determine staffing ratios as it depends on a combination of a nurse’s experience and patient’s acuity. Unfortunately, in practice, it is often determined by other factors. At some institutions, the number of nurses is only a percent of what is actually needed. Staffing in Nursing Currently, self-reported medication errors provide minimal information to organizations. The discrepancies in terms of reported-to-actual rates are widespread. Medication errors are typically reported through institutional reporting systems such as incident reports alone. However, it is estimated that relying on incident reports to provide data miss up to 95% of the medication errors. Reporting systems are dependent on the nurse’s ability to recognize an error had occurred. Therefore, it is the nurse’s regression whether an error was made or not. Some nurses may find simple mistakes as trivial that they thought it is no longer necessary to be reported. Thus, it is necessary that the institution to make sure the nurses believe that every error committed warrants a reporting. Instances such as denial that an error was committed are other issues that must be discussed among the healthcare institutions. Sometimes, admitting ones mistake is too difficult for a person, especially in healthcare practitioners who were trained to follow certain protocols. Committing an error and admitting may be too embarrassing to them. Furthermore, their fear of being punished for the mistake committed in medication administration is too strong they would rather not report such mistake. It is at the same time surprising that nurses themselves believe that only 25% of all medication errors are ever reported. Data Gathering To obtain the information necessary for this research, interviews are conducted among the medical staff in a healthcare institute. Ton separate days, meetings were set up with the Administrative Director of Nursing, 3 West Nurse Manager, two charge nurses, and staff members to give and obtain test results and additional inputs on the research. The respondents are chosen based on their experiences and knowledge about the given problem. They were at the same time considered for this research for they are assumed to have their first-hand experience on the issue at hand. Based on the results of the interview gathered as well as the reports presented during the interview, significant data was identified. After gathering the annual incident reports that were filed by the nurses, it generated the most common medication errors based on the 30,195 patients that were admitted in the health care institution. The most common among the medication errors observed with 13.0% prevalence is the nurse’s failure to adjust dosage in response to a change in hepatic or renal function of the patient. It is followed by their inability to check whether the patients have history of allergy to the same or related medication, which is at 12.1%. At 11.4%, nurses commit the mistake of identifying the wrong drug name, dosage form, or abbreviation on the order that physicians give them in order to administer to the patients. Then, at 11.1%, incorrect dosage calculation is also one of the common medication error identified. Atypical or unusual dosage consideration that is usually based on the weight of the patients is also often a mistake committed at 10.8%. Significance to Nursing Medication error is an issue that dates back to the establishment of the first hospital where patients were not give the proper nursing care that are necessary for them to recover from the diseases or illnesses that they were suffering from (Clarke 2003). However, patient care is a complex discipline that requires an understanding of the consistency of its environment. As changes continue to happen in a healthcare environment, no one could predict what would happen next. Such unpredictability, along with “awkward technology, insufficient nurse staffing, and constant adjustments in assignment from patient admissions, transfers, and discharges,” instances of medication error could occur (Fasolino 2009). On the other hand, when the relationship of these factors that cause such failure in the administration of patient care is identified, appropriate actions may be implemented in order to make sure the prevalence of medication error is decreased. Application of Leadership/Organizational Theory This study applies the General system theory, which is another situational approach to leadership where people are studied within their environment and their roles as builders of that environment they are confined in. In the nursing environment, analyzing the different parts of the system, and the relationship between and among those parts, including the system’s purpose, beliefs, and tasks would help the system function perfectly (La Monica 1986). Applying such theory in this study would involve the identification of the relationship between insufficient nursing staff and medication errors. Analysis of Implementation Process The implementation of the project was successful due to several factors. Since this project simply evaluates the results of the interview and the reports that were presented by the interviewer, there were no stressors that were encountered. The interviewees were also notified of the necessary information needed from them before the meetings, thus, they came well prepared for the interview. Evaluation According to the data gathered, it shows that there was little correlation to short staffing and medication errors. Short staffing actually contributed more to increased falls, hospital acquired pneumonia, pressure ulcers, urinary tract infections and failure to rescue, and increased amount of post-operative wound infections. In addition, short staffing also contributed to decreased patient satisfaction, nurse burn-out and increased overtime. References: Clarke, S. (2003). Balancing staffing and safety. Nursing Management, 34, 44-48. La Monica, E. (1986). Nursing Leadership and Management. Monterey, California: Jones and Bartlett Publishers. Read More