Medical Errors: Medication Administration Error - Essay Example

MEDICATION ADMINISTRATION ERROR Insert Insert Insert Insert Executive Summary It is a fact that error is to man and man is to error. Even though errors form part of every practice, majority of errors are a direct result of complex processes which are preventable. The error in medicine has been described as “the failure of the planned action to be completed as intended or the use of a wrong plan to achieve an aim.” The causes of medical errors have been categorized into two broad areas which include active failure and latent conditions. What comes to mind most often is active failure when an error is mentioned due to the attention on individual acts in medicine (Bates, 2001). Active errors assume different forms including lapses; this involves failures in memory that prevents the planned actions from being implemented. Slips; this involves performing a familiar action in a wrong away. Mistakes; are refereed to as a trend of reasoning leading to wrong outcome of choices. Latent conditions refer to systemic properties that result to errors. They may include system interfaces and management practices. It is summarized by the descriptions of Don Berwick that “every system is perfectly designed to achieve exactly the results it gets.” The nature of today’s primary care and frenetic pace of management in care within medical practices have made the probabilities of errors to become great. The Robert Graham Policy Centre has come up with a patient safety model called “toxic cascades.” It describes how small unnoticed errors can add up to become torrents. Research studies on office-based errors in primary care have been found to be of different categories. It shows that communication problems results into 24% of the errors, 20% are caused by discontinuity of care, 13% are as a result of missing charts, 19% from lab results, 8% are caused by clinical mistake, 8% resulted from prescribing errors, and the other 8% by other errors. The study revealed that medical errors are by and large a result of latent conditions and not active failure as had been believed. The medical infrastructure has become fragile and the risk adverse outcomes has gone low, despite the fact that delayed care, patient dissatisfaction, and worsening illness are still very common concerns in medical practices. Studies on error in health care by the National Patient Safety Foundation (NPSF’s) have led to the conclusion that “the ambulatory inpatient dichotomy is a false one. We have to think about populations and their continuum of care.” (Brennan, 2000). Turnbull the executive director of NPSF’s has put recommendations that in order to effectively deal with error reduction, then the programs on the issue should be directed towards vulnerable process areas. This should focus on points of transition in care settings, this recommendation is most importantly in primary care due to the back and forth movement of information between patients from one place to another such as the hospital, lab, and sub-specialists. The work of error reduction is undertaken through an overview of safety practices in the discussions of “high reliability” organizations by Dr.Reason. Introduction High reliability organizations encapsulate those with a very small margin of error with catastrophic effects incase of a disasters such as those of nuclear plant disaster or airlines. As a result, there are three basic points in dealing with error a cording to Dr.Reason. These include, identify, prevent, and absorb. Successful identification of errors should entail an establishment of a culture of safety and reporting of errors. It involves the description of clear solutions between blameless and blameworthy errors. This is enabled by ensuring that everyone in the organization has the empowerment to point out errors that they think jeopardize patient safety which can be difficult to achieve in the traditional hierarchy of medical medicine (Dubois, 2008). It suggests that errors must be prevented to the fullest extent possible through prevention measures that reduce reliance on memory through the administration of checklists, flow sheets, tickler systems among others. Improvement in the communication system can be achieved through the use of handheld computer and electronic medical records. Standardization is a method of error prevention which entails office formularies, and guidelines synthesis. Other measures of error prevention include, training on error identification and prevention as well as error-proofing systems. These measures entail the employment of staff in-services, fail-safe to avoid prescribing two drugs that interact fatally. There is a need in the design of systems so that they can be able absorb a certain degree of error without adverse effects on the patients. This can be achieved through two buffers including time lapses and redundancy. A high reliability organization is characterized by minimization of variability and the ability to adapt to the quickly to emergency conditions. But the most important aspect of high reliability organization as described by Dr. Reason as a “constant preoccupation with the possibility of possibility of failure” (Couch, 2008, p. 35). Patient Safety There is overwhelming evidence that many patients are harmed from health care resulting in permanent injury, increased length of stay in hospitals and even death. Over the last decade adverse events have occurred not as a result of intentional actions by the health care providers, but because the health system of today has become so complex that successful treatment depends on a range of factors and not just the competence of the practitioners. Research studies have found that, when so many people and different kinds of care providers are involved in health care provision system, it makes it difficult to ensure patient safety unless the system is redesigned to efficiently and economically facilitate timely and complete information and understanding by healthcare professionals. Safety of patients has been an issue for all who provide health services whether privately commissioned or funded by the government (Couch, 2008). The prescription of antibiotics which often disregards the patient’s underlying conditions as to whether the antibiotics will help the patient or the administration of multiple medication without the due regard to the potential adverse reactions with the patient has the ability for harm and patient injury. Misuse of technology is not the only potential source of harm for patients; other causes of harm include poor communication between different health care providers and the delays in receiving recommended treatments. Patient safety provides a broad subject which encompasses the use of modern technology including electronic prescribing and redesigning services and hospitals, being a tem player and proper washing of hands. Patient safety and medical error reduction has been a pressing matter for policy reform in health care sector in U.K. Most comprehensive policy recommendations on patient safety and medical error have been implementing in the attempt to improve the health care service delivery in Great Britain. Research studies have shown that deaths that results as a result of medical error has been higher than that from motor vehicle accidents, breast cancer, or AIDS in the last over ten years. As a result, the American government has introduced a host of bills in the Congress including the SAFE (Stop All Frequent Errors) Act of 2000, Patient Safety Improvement Act 2002, and the Medication Errors Reduction Act of 2001. Despite the fact that these bills have not made it to laws they show the ongoing debate and recommendations on the need of patient safety and medical error reduction (Steel, 2001). The IOM recommendations have provided a catalytic reaction in the reform of the subsequent patient safety either by regulations or institutions. In an attempt to be part of the context of any discussion on the ethical basis of patient safety, medical institutions have adopted policy-relevant amendments to comply. The Institute of Medicine report has been taken as a public policy document which proposes the need for intervention by the government in addressing problems of great concern to great concern to public health and health care financing (Gilbert, 2007). The report has observed that a lag in the health care results in a negative effects on the performance of other industries in safety and error prevention. This is because medicine has no established designated agencies that can set and communicate priorities for safety unlike the case of occupational safety. This has led to the recommendations of the establishment of keystone establishment of a centre for patient safety with the responsibility of overseeing national goals for patient safety. The value of patient safety is best understood in the two longstanding principles of health care ethics. These include the beneficence, which is the positive response in preventing harm, and the nonmaleficence, which is the negative obligation in refraining from causing harm. The principle of beneficence propagates a moral discussion against errors of omission relating to misdiagnosis or failure in the provision of required treatments. It establishes the arguments against errors of commission such as wrong patient drug administration, surgical slips, or transmission of nosocomial infection. These two principles provide forms the obligation of “to do no harm.” The relationship between the doctor and the patient has been traditionally regarded as fiduciary. There has been a power disparity between the patient and the doctor with the patient being vulnerable as the doctor’s help are seen to focus obligations on healthcare providers in promoting patient’s interests (Bedell, 1993). Medical error and injury often happens to an identifiable person. From the fiduciary ethics point of view, the patient is often the focus of the responsibility to do no harm. The definition of safety by IOM as “freedom from accidental injury” is considered to be patient-centered focus. It recognizes that the definition is the primary goal from the perspective of a patient. Patient safety goal can be justified by the utility principle which is the achievement of the greatest good across the population. Policy recommendations today are based on patient safety as a public health problem with the requirement of strategies on improving the overall safety in health care system which are based on utility (Schimmel, 2001). Research studies have found that many features of patient safety involve the individual commitment to practicing safety rather than financial resources. Doctors and nurses can improve on patient safety through frequent engagements with patients and their families, learning from errors, checking procedures, and effective communication within the health care team. Such activities have been proven to minimize harm to the patient and therefore help in saving costs. Errors when reported in time and properly analyzed can help in the identification of the main contributing factors. The understanding of such factors leading to errors is important in the creation of changes that help prevent errors from occurring. The public health ethics has provided for the point of view in which the patient population is the normative focus in the aggregate domain of healthcare. As such, safety improvements are measured in terms of epidemiologic statistics as the target goal of IOM of “fifty percent reduction in errors over five years.”Patient safety value is also seen to derive from its economic utility. It has been estimated by IOM that the total cost of preventable medical error is ranging between seventeen and twenty-nine billion dollars a year in U.S. The report relies on the assumption that reducing these errors buy 50% in five years is justified by the reduction of costs associated with them (Phillips, 2001). It is also feared that the utilitarian and the fiduciary patient safety systems can easily come into tension. It is observed that although the incentives for reducing the costs associated with preventable error due exists, the economic levels of such incentives is not yet assured. It has been established that without clear prioritization of fiduciary justification for safety that focuses on the patient welfare as a policy requirement, safety measures can easily be reduced to their economic values. In such situations, policy makers might consider that economic considerations alone can justify certain safety trade-offs (Rosner, 2000). The biggest ethical challenge for patient safety reform is in the fact that strategies for overall patient safety improvement do posses the potential of compromising obligations to individual patients. The IOM report recommends reporting of adverse events as mandatory while lesser harms and near misses as voluntary. However, this has been found to portray a paradoxical effect in making safety improvement efforts contingent on a patient having serious harm. The IOM expresses accountability for harmful medical errors as a call for nationwide mandatory system in reporting adverse events and the creation of performance standards on patient safety and quality improvement in the health care organizations (Sharpe, 2008). Accountability is based on the reports from the public which is grounded on the right to know and be protected from hazards. This also is sourced from the principle of fairness. From the perspective of regulation, health settings hazards are a matter of safety for the public. Mandatory reporting often generates standardized information that is used in the understanding and tracking hazards i0n taking preventive actions. The IOM report states that “the public has the right to expect health care organizations to respond to evidence of safety hazards by taking whatever steps are necessary to make it difficult or impossible for a similar event to occur in the future. The public also has a right to be informed about unsafe conditions” (Phillips, 2001). Fairness principle often operates on two levels in the mandatory reporting. It states that mandatory reporting intension is to make even the playing field for health care providers in order to make none exempt from data collection on safety, or from civil liabilities incases of patient harms. Mandatory reporting is also aimed at providing avenues for harmed patients to acquire access to information regarding the surrounding circumstances of an injury so as to seek justice for harm associated with care. The serious propositions on meaningful public access to information on serious harms states that, “requests by providers for confidentiality And protection from liability seem inappropriate in this context” (Pellegrino, 2006, p. 57). Quality, clinical Governance and assurance Quality and patient safety is dependent on good clinical governance arrangements, relevant national standards and legislation. Clinical governance is described as a framework within which healthcare teams are accountable for safety and satisfaction of patients, and for quality. Clinical governance is built on the model of chief executive officer (CEO) working in partnership with other leaders in the profession. Its key characteristic is a culture of commitment to the agreed service levels and quality care to be provided. The assurance check of an organization provides for the knowledge baseline for clinical governance. Its intention is to provide a guide in the review of structures and processes used pin the achievement of good clinical governance outcomes. Medical assurance check in an organization aids the CEOs in the determination of what clinical governance is in place. When undertaking conducting the assurance check, it will aid in the establishment of the baseline for an organization. It helps in putting a strong foundation in good clinical governance across the continuum of care (Thomasma, 2008). The clinical governance and assurance check provides four main possible uses to an organization. It helps in putting and confirmation of clinical governance arrangements in place. This further helps in the creation of an action plan for the development of the arrangements which intern assists in planning and implementing new arrangements in an organization which are directed towards monitoring of the progress being made. The principles of clinical governance is to assist health care providers with a descriptive ten principles that when provided then an organization will be able to perform smoothly with a great degree of patient satisfaction (Kohn, 2000). The principles are geared towards informing all the actions and providing the guide in choosing among options in decision making. The governance principle is based on the idea that everyone is responsible in the running of health sector through the use of the nine principle descriptors. The principle of patient first is based on the partnership of care that prevails among the patients, families, healthcare providers in the achievement of timely and high quality services, safe and easily accessible services across the care sector. The safety principle here involves the control of risks to achieve efficient and positive results for staff and patients. Clinical governance provides for individual responsibility in which health care teams members of the public, patients, assume individual responsibility for their own and that of others health needs. Each employee is supposed to have a job description spelling out the responsibilities, purpose, standards required in their roles and accountabilities. Provision of quality care has a direct impact on the health status of patients in terms of care experience, the safety of care and the cost of care. It also reflects positively on the reputation of an organization (Schimmel, 2011). Quality The concept of quality has been in existence over along period of time, as much as its meaning has evolved over time. Quality management in the past meant ensuring certain specifications and lay down by organization. It has been viewed as something that encompasses entire organizations, not only the production process. It has been viewed as the total management of health care provisions. The general definitions of quality are referred to as the act of meting or exceeding customer expectations. Quality dimensions Highly quality care has become as important as the ethical responsibility provision. The achievement of heath care provision depends on four major quality dimensions which include: The quality of reporting; this provided in the medical act of the Medicare Modernization Act of 2003 which is implemented by the Reporting Hospital Quality Data for the Annual Payment Update program. The second one refers to the Quality of Documentation; this includes the accuracy of documentation in of patient medical records. Its indicators are derived from information contained in the patient records. The third one is referred to as The Quality of Quantity; it involves the study and measurement of quantity of proven quality care. It is concerned with the quantity and not the quality of health care. The fourth dimension is referred to as The Quality of patient satisfaction; It has been shown in a survey by the American Consumer Satisfaction Index that health systems has outperformed the private sector provision for the achievement of customer satisfaction (Scott, 2003). A robust governance framework is essential pin ensuring quality throughout an organization. It provides an assurance to the governing council of an organization that the essential standards of quality and safety are being delivered on. This enhances the assurance that quality governance processes are deeply rooted throughout the organization. Studies on quality governance framework have found that it helps in raising the standards and profile of quality for the boards of an organization. Quality governance has been described as the combination of processes and structures below and at the board levels in order to provide trust-wide quality services (Kraman, 2006). Quality governance framework works under the four main domains including; strategy, capabilities and culture, processes and structures, and measurements. The strategy domain is concerned with whether the quality drives trust’s strategy and whether the board is sufficiently aware of risks to quality. While the capability and culture domain is concerned with whether the board has the necessary skills and knowledge, leadership that ensures the delivery of quality and to promote a quality focused culture throughout the trust (Bedell, 1991). Processes and structures involves the provision of clear roles and accountability framework in relation to quality governance, the presence of a clearly defined and well understood processes for resolving matters as well as active engagement of staffs, patients and key stakeholders. While the measurement domain deals with the appropriate analysis of quality information the assurance that the board ensures robust quality information as well as its effective use. This guidance is aimed at helping the board understand the requirements of a trust’s internal assurance mechanism that assures the organization’s wide spread processes for the governance of quality and improving decision making in the discharge of responsibilities in the improvement of care for patients (Steel,2001). Good quality governance should be based on the concepts of; engage and cascade, assure and escalate. The concept of Engage and Cascade involves the engagement with stakeholders to set quality priorities and standards and communicating across the whole organization. This involves engagements with others both in the organization and outside of the organization in setting priorities and expectations. The priorities and expectations should be communicated clearly and cascaded to levels of the organizational structure. Assure and escalate concepts ensures the delivery of high quality care with effective management of risks (Pellegrino, 2009). Figure 1: Themes underpinning the guidance in good quality governance in health care Patient safety incident It began 10 May 2013 when a lady by the name Nancy aged 35 was admitted to the hospital to deliver her second born baby in uncompleted caesarean birth. The obstetrician and the anesthetist set the epidural catheter as usual. On the following day, Nancy reported that she had a sharp pain in the spine and on the day before the removal of epidural, she bumped the epidural site accidentally. As time moved she continued to complain about the pain and tenderness in her lumber region. The anesthetist conducted an examination and diagnosed pain of muscular. However, the pain continued and she was limping by the time she was discharged (Leape, 2003). For the next one week Nancy stayed at her home in the country. As the pain was still persistent, she called the obstetrician who treated her in the hospital and informed the doctor a bout her shaking, fever, headaches, and intense low back pain. On 20th May, Nancy and her baby were examined by the local medication officer who recommended that they both be admitted in the district hospital for back pain and jaundice respectively. At the district hospital, the admitting doctor observed that Nancy’s back pain seemed top be situated at the S1 joint not at the epidural site as earlier was thought. Following that, treatment ensured for the baby and by 27th May, the baby had improved from jaundice while Nancy’s back pain had not improved yet since she had not been observed by the general practitioner. The doctor admitted that was the case because he had forgotten about her. Another doctor then examined her and diagnosed her with sacroiliitis. She was then discharged with medical prescription for oxycodone, paracetamol and diclofenac and informed Nancy’s obstetrician of his diagnosis. The medication assisted Nancy’s condition for sometime until 3rd of June when her situation deteriorated (Kohn, 2003). Nancy was then taken to the local county hospital by her husband. On arrival at the hospital she started convulsing and mumbling. The medical officer then recorded in the medical records “excessive opiate usage, sacroiliitis.”By this time her condition was critical and she ambulanced to the district hospital. At the arrival at the hospital she was unresponsive and was in need of intubation. Her pupils were still dilated and fixed and her condition did not improve until she was transferred to the second city hospital where it was determined that she had no brain function as a result life support was withdrawn (McLamb, 2007). On the examination at the postmortem, it was discovered that she had suffered from epidural and meningitis. These infections involved the spinal cord from the lumber region to the base of the brain. The cultures also showed a methicillin resistance staphylococcus aureus (MRSA) infection. Coronial investigation summarized that Nancy’s abscess could have been diagnosed earlier than it was. The incidences that led to Nancy’s death could be attributed to the problems of negligence and poor quality health systems. The failure to keep adequate notes with differential diagnoses led to delay in the diagnosis of life-threatening. The anesthetist in this case seemed to have been concerned with Nancy’s case but failed to consult with the medical library and did not record this in her clinical notes. He also failed in the communication of the risk of what he thought to be “neuropathic” pain to Nancy before she was discharged. It is also clear that evidence based guidelines were not followed with respect to epidural insertion. Nancy’s case would have been managed after her discharge by others if her examination were not done in haste after living the hospital (Kohn, 2000). Recommendations The principle goal of patient safety, quality, clinical governance and assurance is to bring forth the importance associated with patient care in health institutions. As such, for the achievement of patient satisfaction in provision of health care services, there needs to a collaboration between the state officials, privacy advocates, and safety improvement advocates in the clarification of the Health Insurance Portability and Accountability (HIPAA) privacy rule safety data collection. Alternative of tort system should be explored by policymakers to serve purposes of compensation and safety improvement (Couch, 2008, p. 55). There should be institutional changes depending on understanding how perceptions are shaped with cultural context. This will aid in the understanding of how errors take place and how actors within a culture think about and deal with them. Health care institutional leaders need more self consciousness to observe “hidden curriculum” of nursing education so that practices that are included in the syllabus are taught through example rather than through conveyance in the official curriculum (Osterweil, 2005). In conclusion, it has been observed that errors cannot be eliminated and can only be reduced to bear minimum. We can learn from them, improve on ways of handling them, and observe treat justly those who affected in one way or the other by them. There is a need for every health institution to have an interest-based mediation to provide a means of opening a direct communication among parties in dispute. This will help in addressing the parties’ needs and interests. In general, there should be an encouragement through teaching in medical schools the habit of adoption of organizational culture and procedures critical for error reduction. It is well known that the threat of medical malpractice has created a culture of silence in medicine, discouraging health care providers from telling patients about problems associated with their care. Even claimants who settle a lawsuit may never know the events surrounding an injury (Weingart, 2000). List of References Bates DW. 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(2008) Faden, Medical Harm: Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness (New York: Cambridge U. Press,; T.L. Thomasma, (2008) For the Patient’s Good: The Restoration of Beneficence in Health Care (New York: Oxford). Weingart SN et al. (2000) Epidemiology of medical error. British Medical Journal, 320(7237):774–777. Appendix The Swiss Cheese Model Read More