Guidelines on Preventing Medication Errors in Hospitals Essay

Guidelines on Preventing Medication Errors in Hospitals Essay

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Quality Improvement:

Decreasing Medication Errors using Barcode Scanning

Medication errors cause injury, disability, birth defects, and death to a large number of patients every year.  They account for over 100,000 reports sent to the U.S. Food and Drug Administration (FDA) each year (FDA 2019).  Quality improvement can assist with decreasing these errors by putting a focus on continually improving processes for medication handling (Marquis & Huston 2017).  Barcode scanning medication administration (BCMA) is one way of decreasing medication error.  This system uses barcodes on medications and patient armbands with scanning equipment and an electronic medication administration record (eMAR) to correctly identify the right patient, right drug, right dose, right time, and right route (FDA 2019).  Human elements can occur, and more support systems are needed to assist in the verification of the five rights (Grissinger 2010).  The IOM (2000) To Err is Human report recognizes many medical errors that occur due to human elements causing a need for safer health system improvements.  Quality improvements to healthcare systems and processes assist healthcare professionals and patients to work together to facilitate safer care (IOM 2000).  This quality improvement paper will further discuss the use of barcode scanning in medication administration to benefit the Institute of Medicine’s (IOM) six aims and goal of preventing medication errors, considerations when using barcode scanning, and patient-centered care to improve the process. Guidelines on Preventing Medication Errors in Hospitals Essay

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The Problem

Medication errors can happen in all stages of the medication operation, from prescribing to administration and are characterized as a patient taking a medication other than what the provider prescribed.  One of the most significant amounts of errors occurs in the administration phase, with thirty-four percent of all errors occurring in this phase (Voshall, Piscotty, Lawrence, & Targosz, 2013).  The five rights of medication administration have always been standard practice and are an excellent tool for nurses to use to prevent medication error but lack troubleshooting suggestions when problems arise (Grissinger 2010).  The IOM (2004) recommends medication administration be an initial work redesign in nursing practice to prevent medication error.  The redesign will allow for more opportunities to prevent errors before occurring.  Currently, only two percent of medication administration errors are intercepted prior to reaching the patient (Voshall et al. 2013).  Problems with similar packaging, similar drug names, and similarities in drug labeling designs have been noted to cause medication error, causing the FDA to come up with guidelines to help manufacturers prevent these issues (FDA, 2019).  The CDC has recognized the problem with medication errors creating a program for monitoring adverse drug events (ADEs) that occur due to medication error (CDC, 2017).  These events count for $3.5 billion in spending on medical costs and approximately 350,000 hospitalizations each year (CDC, 2017).  The IOM (2006) committee found that the total number of preventable ADEs are at least 1.5 million per year in the United States alone.  These ADEs are the cause of hospital-acquired injury and are the most common of injuries (Leung et al. 2015).  The good news about this issue is that medication errors are preventable with continuous quality improvement helping to shape practice utilizing such technologies as BCMA. Good work here! Guidelines on Preventing Medication Errors in Hospitals Essay

IOM Aims for Quality

Safety

Safety in practice continues to be a focus in healthcare as an aim for quality improvement and defined by the IOM (2001) as preventing harm to patients from practices designed to help them.  The Joint Commission, known for high-quality standards, oversees the accreditation and certification of health care facilities in the United States.  Every year the Joint Commission creates a report of patient safety goals for health care organizations to focus on, and using medications safely has consistently been on the list of goals (Joint Commission 2019).  The IOM (2004) recommends one way to improve safety is to create and sustain a culture of safety amongst workers.  To create a culture of safety, they suggest to clearly define safety goals, acknowledge successes, encourage error reporting, educate on error detection, and provide feedback to increase safety (IOM 2004).  Great job on this paragraph! Guidelines on Preventing Medication Errors in Hospitals Essay

Medication safety is a complex process affected by many different outside elements.  Barcode administration technology can improve the medication process by improving medication administration safety.  Marcias, Bernaneu-Andreu, Arribas, Navarro, and Baldominos (2018) found that barcode administration system decreased the number of errors and the severity of their impact using a pre/post-intervention study.  To provide safe quality care, this technology needs to be recognized and introduced as a tool, not in place of nursing assessment, skills and judgments when administering medications (Bowers, et al. 2015).

Effectiveness

            The IOM defines effectiveness as an aim to providing care based on scientific knowledge and avoiding redundant or unnecessary services (IOM 2001).  Medication barcode scanning has helped streamline, simplify, and standardize the medication administration process, making it more effective (Leung et al. 2015).  When using barcode scanning, documentation becomes more effective by ensuring real-time charting of medications on the electronic medication administration record (eMAR) (Leung et al. 2015).  Based on a systemic review comparing medication error prevention, barcode scanning has shown to decrease errors (Berdot, Roudot, Schramm, Katsahian, Durieux, & Sabatier 2015). In contrast, self-guided education and a designated medication nurse showed no change in errors found (Berdot et al. 2015). Good! Guidelines on Preventing Medication Errors in Hospitals Essay

Efficiency

            The best way to improve efficiency, as recommended by the IOM (2001), is by decreasing quality waste and minimizing administrative and production costs.  Waste is considered using additional resources without patient gain (IOM 2001).  In a letter to state Medicaid Directors, Kuhn (2008), Deputy Administrator for Center for Medicaid and State Operations, explains in detail the recommendations for Medicaid and Medicare Services (CMS) to no longer pay for events that are considered Never Events, following with a list of all events considered Never Events.  Medication error causing death or disability is on this list (Kuhn 2008).  Lack of reimbursements to injuries caused by medication error causes loss of revenue and creates an initiative to decrease errors.  Organizations may assume the upfront cost of BCMA is too much, and they are unable to rationalize the usage of BCMA, but a cost-benefit analysis shows the breakeven point occurs in the first year (Voshall et al. 2013).  This is due to the substantial cost of medication errors and the amount of savings on decreasing these errors once BCMA is implemented (Voshall et al. 2013).  Well done here! Guidelines on Preventing Medication Errors in Hospitals Essay

Equity

Equity in healthcare is defined by the IOM (2001) as equal services to benefit all people in the United States.  Unfortunately, throughout the U.S., there are still inequities in care due to lack of health insurance and prejudice.  This can be seen amongst hospital systems with a lack of technology and processes to increase patient safety.  Even though the recommendation for barcode scanning by the American Society of Health-System Pharmacists (ASHSP) occurred, only 35% of American hospitals have implemented this system (Berdot et al. 2015).  This causes inequity in the care given to those in hospitals without BCMA.  The Leapfrog Group (2017) operates as a not-for-profit watchdog organization whose goal is to foster change in U.S. healthcare by requesting hospital transparency to influence value-based care.  They have implemented a standard for all hospitals to implement a BCMA in all med-surg and critical care units with compliance reporting and best practice processes (The Leapfrog Group 2017).  This will help improve equity by actively encouraging all hospitals to implement the BCMA system to decrease medication errors, lowering adverse outcomes for patients.  Change is hard to enforce and may cause push back by nurses when implementing BCMA, but a descriptive study showed a substantial level of nurse satisfaction when using the system (Voshall et al. 2013).  More research is required to verify the reduction of medication errors using BCMA to help hospitals reach readiness for change to increase the implementation of BCMA. Great job here! Guidelines on Preventing Medication Errors in Hospitals Essay

Timeliness

Timeliness is significant in every aspect of life, and healthcare must take responsibility to cut time off every process to improve workflow, decrease patient complications from a delay of care, reduce emotional stress from waiting, and increase respect for patient’s time (IOM 2001).  Timeliness in medication administration is essential to improve nurse workflow and administer medications properly within a timeframe of 30 minutes before and 30 minutes after the medication is due, a standard that varies with individual hospital policy.  Some nurses may be skeptical of BCMA due to a worry of an increase in time used to administer medications.  A before-and-after study was done using direct observation concluding that the time taken when using bar-coding was unchanged (Voshall et al. 2013).  When administering medications, the timing of those medications need to be considered and collaborated with the prescriber, nurse, and pharmacist.  This is important when implementing BCMA as it is essential to have a user-friendly system and allow for easy modification of administration time due to unforeseen events.  This is only to increase compliance as the influence of BCMA on wrong time errors, which aren’t as clinically significant, is unclear (Shah, Lo, Babich, Tsao, & Bansback 2016). Good! Guidelines on Preventing Medication Errors in Hospitals Essay

Patient-centered

            The aim patient-centeredness concentrates quality efforts on increasing patient overall experience of healthcare and systems that create success or spotlight those that fail to focus on patients (IOM 2001).  The IOM (2006) states the first step to improving outcomes, quality, and preventing medication error is to encourage the patient to participate, be connected, and pay attention to the care given by providers.  The relationship between patient and provider should be more of a partnership.  The healthcare team should use communication with the patient as a two-way street (IOM 2006).  Listening to the patient needs to become a top priority as it helps the provider give more personalized care.  Education is another tool that can be used to include the patient.  Medication uses, side effects, contraindications, proper administration time, and tips to improve effectiveness need to be standard education topics to improve the overall health of the patient (IOM 2006).  In turn, the patient and their family should take responsibility for keeping medication records and being involved in the administration process during hospitalization. Guidelines on Preventing Medication Errors in Hospitals Essay

Planning and Collaboration

Interdisciplinary Teams

The team needed to implement BCMA is a collaboration between pharmacy, nursing, and Information Technology (IT).  The technology required for BCMA will require an efficient wireless network needing IT to implement, maintain, and troubleshoot problems with all technology and wireless network (Ross 2008).  Pharmacy is necessary to stock and verify medications, adjust medication orders to align with exact medication type (capsule vs. liquid, for example), adjust medication schedule when complications interfere and answer administration, interaction, and medication questions as they arise (Ross 2008).  Nurses carry out the task of medication administration using BCMA with the support of Pharmacy and IT.  As previously stated, it is crucial to include patients as part of the team by educating them in the process of BCMA to increase autonomy and give them a sense of responsibility to help achieve safe care (IOM 2006).  Ross (2008) found this collaboration and efficient communication between Nursing, Pharmacy, and IT was critical for the execution of BCMA. Good job here! Guidelines on Preventing Medication Errors in Hospitals Essay

Information and technology

The BCMA system relies on several different technology systems to work together, creating one fluid system, including an automated medication dispensing cabinet, electronic medical record with an eMAR, medication labeling and packaging system in pharmacy, and a correct patient armband with readable barcode.  Workstation computers will be needed at every patient bedside, or workstations on wheels (WOWs) will be required to bring the technology to the bedside.  Nurses may have difficulty using WOWs due to the system in need of adequate battery charge or lack of access to WOWs when needed.  As previously stated, medication records need to allow documentation of the exact reason for medications being late and allow time adjustments from a set schedule to ensure nurse compliance of BCMA use (Strudwick et al. 2018).  This can be used when the patient is unable to take medications because of vomiting, off the unit for a procedure, or the wrong schedule began with the original order.  Nurse and patient education on technology are essential for proper usage of BCMA to increase compliance, decrease workarounds, and decrease medication errors (Strudwick et al. 2018).  Great work

Quality Improvement

Medication errors can be tracked by nurse reporting, reviewing patient medical records, or through direct observation.  Nurse reporting can be biased due to a lack of knowledge of error or fear of termination (Berdot et al. 2015).  Reviewing charts is an ineffective way to detect medication errors due to the lengthy time it takes to go through every chart (Berdot et al. 2015).  This leaves direct observation as the best measure of error during the study (Berdot et al. 2015).  Nurses may change practice when observed, but when observed before and after the intervention, outcomes will show equal improvement during both measures (Berdot et al. 2015).  When BCMA is implemented, barcode scanning rates need to be monitored for noncompliance and workarounds to point out the clinical areas in need of further education and reinforcement of the importance of use (Strudwick et al. 2018).  The Healthcare Information Management Systems Society (HIMSS) recommends the usage of BCMA to decrease medication errors with a scanning rate of 95% and above on patient armbands and medications (Strudwick et al. 2018).  Guidelines on Preventing Medication Errors in Hospitals Essay

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Evidence-based

Nurses have a direct link to how effective and successful BCMA is to decreasing medication errors.  Workarounds are ways nurses use shortcuts and bypass proper steps to using BCMA technology.  These can include silencing alerts without addressing them, using a medication label or patient armband other than the original, and manually entering information if the technology isn’t working without using proper troubleshooting mechanisms (ASHP 2018).  This is when monitoring user compliance is vital to decreasing medication errors using BCMA (ASHP 2018).  More research is required to formulate standards for educating nurses to use BCMA and to reduce workarounds (Strudwick et al. 2018).  A systematic review done by Voshall, Lawrence, Piscotty, and Targosz (2013) showed that BCMA has been successful in preventing medication errors, and improving the quality of patient care as well as decreasing healthcare costs.  Another systematic review by Shah, Lo, Babich, Tsao, and Bansback (2016) concluded that BCMA helps improve checking of patient identification and decreases significant medication errors. Guidelines on Preventing Medication Errors in Hospitals Essay

Conclusion

            The IOM aims have helped to shape quality improvement in the U.S. healthcare system and decrease medication errors.  Medication errors have substantial consequences for patient outcomes and are costly for healthcare.  Studies show BCMA technology reduces medication errors and improves patient quality of care.  This can decrease cost long term if compliance is monitored, and standards are followed.  More research is needed to create BCMA’s best practices and find processes that improve nurses’ use of workarounds.  Continued support for BCMA is required to increase hospitals’ desire to invest in technology in their organization to increase equity of care.  Using a collaborative team, including the patient at the center, will help the efficiency of BCMA to reduce medication errors.  Continuous quality improvement is necessary to increase compliance of BCMA use, create a culture of safety, and reduce medication errors. Guidelines on Preventing Medication Errors in Hospitals Essay

References

American Society of Health-System Pharmacists (2018).  ASHP guidelines on preventing medication errors in hospitals.  Retrieved from https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/preventing-medication-errors-hospitals.ashx

Berdot, S., Roudot, M., Schramm, C., Katsahian, S., Durieux, P., & Sabatier, B. (2016).  Interventions to reduce nurses’ medication administration errors in inpatient settings: A systematic review and meta-analysis.  International Journal of Nursing Studies, 53, 342-350.  http://dx.doi.org.libproxy.usouthal.edu/10.1016/j.ijnurstu.2015.08.012

Bowers, A. M., Goda, K., Bene, V., Sibila, K., Piccin, R., Golla, S., Dani, F., & Zell, K. (2015).  Impact of barcode medication administration on medication administration best practices.  CIN: Computers, Informatics, Nursing, 33(11), 502-508.  DOI: 10.1097/CIN.0000000000000198

Centers for Disease Control and Prevention (2017).  Medication safety program.  Retrieved from https://www.cdc.gov/medicationsafety/basics.html

Grissinger, M. (2010).  Medication errors.  The five rights: a destination without a map.  P&T: A Peer-Reviewed Journal for Managed Care & Formulary Management, 35(10), 542-542.  https://www-ncbi-nlm-nih-gov.libproxy.usouthal.edu/pmc/articles/PMC2957754/

Institute of Medicine (2000).  To Err is Human: building a safer health system (excerpt).  In Kohn, L.T., Corringan, J.M., & Donaldson, M. S. (Eds.), Washington DC: National Academies Press.  Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25077248

Institute of Medicine (2001).  Improving the 21st-century health care system.  Crossing the Quality Chasm: A New Health System for the 21st Century, (ch. 2).  Washington DC: National Academies Press.  Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK222265/#ddd00039

Institute of Medicine (2004).  Institute of Medicine report, keeping patients safe: transforming the work environment of nurses.  ISNA Bulletin, 30(2), 1-6.  Retrieved from https://web-a-ebscohost-com.libproxy.usouthal.edu/ehost/pdfviewer/pdfviewer?vid=16&sid=f4c6afb8-2a90-4bd2-b9bb-a947e7542e81%40sessionmgr4008

Institute of Medicine (2006).  Preventing medication errors report brief.  Retrieved from https://www.nap.edu/resource/11623/medicationerrorsnew.pdf

Joint Commission (2019).  2019 Hospital national patient safety goals.  Retrieved from https://www.jointcommission.org/assets/1/6/2019_HAP_NPSGs_final2.pdf

Kuhn, H. B. (2008).  Letter to state Medicaid Director.  Centers for Medicare & Medicaid Services.  Retrieved from https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD073108.pdf

Leung, A. A., Denham, C. R., Gandhi, T. K., Bane, A., Churchill, W. W., Bates, D. W, Poon, E. G. (2015).  A safe practice standard for barcode technology.  Journal of Patient Safety, 11(2), 89-99.  DOI: 10.1097/PTS.0000000000000049

Marcias, M., Bernabeu-Andreu, F. A., Arribas, I., Navarro, F., Baldominos, G. (2018).  Impact of a barcode medication administration system on patient safety.  Oncology Nursing Forum, 45(1), E1-E13.  doi: 10.1188/18.ONF.E1-E13

Marquis, B. L. & Huston, C. J. (2017).  Leadership Roles and Management Functions in Nursing: theory and application (9th ed).  Philadelphia, PA: Wolters Kluwer. Guidelines on Preventing Medication Errors in Hospitals Essay

Ross, J. (2008).  Collaboration – integrating nursing, pharmacy and information technology into a barcode medication administration system implementation.  CARING Newsletter, 23(1), 1-17.  Retrieved from https://web-a-ebscohost-com.libproxy.usouthal.edu/ehost/pdfviewer/pdfviewer?vid=8&sid=0acbd721-5251-435d-be9a-99eb04812c5d%40sessionmgr4007

Shah, K., Lo, C., Babich, M., Tsao, N. W., Bansback, N. J. (2016).  Bar code medication administration technology: A systemic review of impact on patient safety when used with computerized prescriber order entry and automated dispensing devices.  The Canadian Journal of Hospital Pharmacy, 69(5), 394-402.  doi: 10.4212/cjhp.v69i5.1594

Strudwick, G., Reisdorfer, E., Warnock, C., Kalia, K., Sulkers, H., Clark, C., & Booth, R.            (2018).  Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.  Journal of Nursing Care Quality,           33(1), 79-85.  DOI:10.1097/NCQ.0000000000000270

The Leapfrog group (2017).  Latest report: First-ever data on bedside bar-coding shows hospitals have the technology to safely administer medication, but fall short on using it effectively.  Retrieved from https://www.leapfroggroup.org/news-events/latest-report-first-ever-data-bedside-bar-coding-shows-hospitals-have-technology-safely

U.S. Food & Drug Administration (2019).  Working to reduce medication errors.  Retrieved from https://www.fda.gov/drugs/drug-information-consumers/working-reduce-medication-errors Guidelines on Preventing Medication Errors in Hospitals Essay

Voshall, B., Piscotty, R., Lawrence, J., & Targosz, M. (2013).  Barcode medication administration work-arounds.  Journal of Nursing Administration, 43(10), 530-535.  

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