Improving Patient Safety In Primary Care Settings Discussion

Improving Patient Safety In Primary Care Settings Discussion

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S – Situation: Healthcare-related situation (S) prompting a systems-level patient safety concern

The healthcare organization is concerned with the safety of patients. With the significant increase in demand for healthcare services, nurses administer medications based on the physician’s diagnosis and order. However, this practice leads to medication discrepancies where patients are administered the wrong medication or inappropriate dosage, jeopardizing patient safety due to health complications related to medication errors. Additionally, the high rate of medication errors decreases patient satisfaction and makes the clients lose trust in the healthcare system. Delay during discharge due to miscommunication is another challenge facing the medical facility. Therefore, this healthcare-related situation triggers discussion regarding concerns of systems-level patient safety associated with medication errors and miscommunication due to their adverse impact on patients, staff, and the medical facility. Improving Patient Safety In Primary Care Settings Discussion

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B – Background: Analyze background (B) information about the concern by doing the following

Based on data obtained from the dashboard, the rate of medication errors in the medical facility has increased dramatically in the last two years. In 2021 and 2022, the actual rates of medication errors in the facility were relatively higher than the set standards. Similarly, the rate of medication errors in the US primary care setting is relatively high. Research shows that between 5 and 7% of total prescriptions in the US lead to medication errors (AHRQ, 2022). In other words, approximately 160 million medication errors are reported in the US annually (AHRQ, 2022). As a result, AHRQ established a patient safety toolkit for preventing medication errors in primary care settings (AHRQ, 2022)Improving Patient Safety In Primary Care Settings Discussion. The AHRQ patient safety toolkit applies to this situation since it provides guidelines, which the medical facility’s management should use in preventing medication errors.

Assess (A) the impact of the safety concern on the patient(s), staff, and the medical facility   The high rate of medication errors and miscommunication at discharge in the medical facility affects key stakeholders negatively. First, medication errors expose patients to adverse health outcomes, including longer stays, high cost of care, and increased mortality rates. Studies show that medication errors are among the major causes of death in a primary care setting (Tsegaye et al., 2020)Improving Patient Safety In Primary Care Settings Discussion. Additionally, miscommunication at discharge makes patients wait for long hours before being cleared. Secondly, medication errors and miscommunication at discharge negatively affect healthcare staff by increasing their workload due to the high number of patients seeking treatment. Lastly, medication errors expose the medical facility to a high operational cost due to the cost incurred in treating error-related health complications. On the other hand, delays during discharge damage the facility’s image to the public. As a result, potential clients shy away from seeking healthcare organization services, which reduces its sales volume and profitability.

Recommend (R) an evidence-based practice change that addresses the safety concern.

The high rate of medication errors and miscommunication at discharge in the medical facility can be addressed by implementing an electronic health records (EHR) system. An electronic health records (EHR) system enhances clinical documentation in healthcare organizations (Baumann et al., 2018)Improving Patient Safety In Primary Care Settings Discussion. Thus, implementing EHR in the medical facility aligns with the principle of the high-reliability organization since it will allow healthcare providers to document essential health-related information, making it easily accessible by authorized parties during healthcare delivery. However, the efficiency of EHR in resolving reported clinical issues might be compromised by the inadequacy of knowledge concerning the system among healthcare providers and the lack of technology needed to support this system. Lack of knowledge among staff members can be addressed by scheduling training sessions for creating awareness regarding the new system among staff before its implementation. On the other hand, the lack of technology needed to support this system can be addressed by ensuring that the medical facility has adopted the latest technology before the implementation of the EHR system. Shared decision-making among key stakeholders will result in the support needed for the successful implementation of the new system. The outcomes of implementing the EHR in the medical facility can be determined through a decline in the rate of medication errors and reduced wait time at discharge. Healthcare providers will rely on patients’ medical information documented in the system during drug prescription and administration, preventing potential medication discrepancies. Additionally, the clinical officer will utilize data documented in EHR during discharge, clearing patients within a short period.

The medical facility is currently using paper documentation to record patients’ medical data. Patients’ health-related data documented and recorded through paper documentation cannot be easily shared or accessed by other multidisciplinary team members involved during healthcare delivery. Therefore, healthcare providers involved in medication prescription and administration tend to make errors due to limited access to patients’ essential medical data. Additionally, the healthcare organization is currently using the team nursing model of care in which nurses from different disciplines work together during care delivery. According to Koopmans et al. (2018)Improving Patient Safety In Primary Care Settings Discussion, a team nursing model of care results in high-quality patient care since multidisciplinary team members utilize diverse skills, qualifications, and competence in making significant clinical decisions. However, team members must share responsibility and work collaboratively to optimize patient health outcomes. The implementation of an EHR system in the healthcare organization will enable multidisciplinary team members involved during care delivery to access and share patients’ health-related information documented in the system, making an informed decision, which will lead to high-quality patient care.

References

Agency for Healthcare Research and Quality (AHRQ). (2022). Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/reports/engage/medlist.html

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Baumann, L. A., Baker, J., & Elshaug, A. G. (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health policy, 122(8), 827-836.

Koopmans, L., Damen, N., & Wagner, C. (2018). Does diverse staff and skill mix of teams impact quality of care in long-term elderly health care? An exploratory case study. BMC health services research, 18, 1-12.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 1621-1632 Improving Patient Safety In Primary Care Settings Discussion