Summary
Medication administration errors are the leading cause of ineffective patient therapy and care. Developing a plan improvement toolkit is necessary to enhance patient safety and quality of care. This task requires utilizing written information, procedures, instructional materials, action plans, precautions, and training. This study will use 12 annotated materials to examine the problem under categories of root causes of medical errors, evidence-based treatments and prevention methods, collaboration strategies, and training to improve competencies and skills.
Annotated Bibliography
The Root Cause of Medical Errors
Connelly, D. (2019). Medication errors: Where do they happen? The Pharmaceutical Journal.
The author of this journal provides a host of medical errors and discusses the source of each error. It is important to deal with the challenge bearing in mind its root cause, and the only way to counter a challenge is by knowing its root cause. This article is important for nurses, especially during root cause analysis which will be necessary for developing a safety improvement plan. The resource can help nurses understand the nursing problems of patients and create strategies easily to help reduce patient risk of medication administration errors.
Al Mardawi, G. H., Rajendram, R., Alowesie, S. M., & Alkatheri, M. (2021). Reducing non-sentinel harm events due to medication errors by using mini–root cause analysis and action. Global Journal on Quality and Safety in Healthcare, 4(1), 27-43.
This article proposes using a mini root cause analysis to investigate medication errors. The root cause analysis investigates nonsensical events resulting from system failure and protocoled pathways to check these events. The research is important to nurses as it provides details about preventing system failures that cause medication administration errors resulting from suboptimal operating procedures and a lack of awareness or updated policies. The report is important to medical staff as a reminder of the importance of staying updated and honing their skills to meet patient needs and reduce risks associated with medication administration. The article is useful in investigating errors to prevent harm and taking necessary measures to ensure patient safety.
Morrison, M., Cope, V., & Murray, M. (2018). The underreporting of medication errors: a retrospective and comparative root causes analysis in an acute mental health unit over a 3‐year period. International Journal of Mental Health Nursing, 27(6), 1719-1728.
The author uses retrospective quantitative analysis to examine medication errors reported by staff to identify their nature and the context in which they occurred. This article is useful in root cause analysis and educating medical staff on the importance of reporting errors and analyzing mistakes to counter the recurrence of medication errors and associated risks. Insight is provided on the frequency of the problem when the problem is detected and the characteristics of the error. The article benefits medical staff due to its emphasis on proper reporting and quality improvement activities. It is useful in guiding medical staff in identifying the cause of medication administration errors and building on mistakes to establish solutions that will prevent a recurrence.
Evidence-based Solutions and Preventive Measures
Sabone, M., Tshiamo, W. B., & Kgatlwane, J. (2020). A Mixed-methods approach to investigating medication errors. SAGE Publications Ltd.
This article presents a special approach to using different methods to conduct root cause analysis for medication errors and establish a prevention strategy. The utilization of several methods in the evaluation of medication errors is essential for ensuring patient safety. The article is useful in identifying and synthesizing the different methods into one holistic approach to medication administration errors. The article is applicable to medical staff in the process of investigating and preventing medication errors. The article is appropriate for formulating a safety plan and effective techniques for dealing with the challenge.
Parker, A. L., Forsythe, L. L., & Kohlmorgen, I. K. (2019). TeamSTEPPS®: An evidence‐based approach to reduce clinical errors threatening safety in outpatient settings: An integrative review. Journal of Healthcare Risk Management, 38(4), 19-31.
The article suggests that team strategies and tools to enhance performance and patient safety are investigated to provide solutions to medication errors. The article is applicable in the utilization of effective communication to reduce medication administration errors. The research showed that TeamSTEPPS is essential in increasing patient safety, morale to staff, satisfaction, and reduction of medication errors. The resource is helpful in the formulation of the implementation plan for solutions to medication errors. It suggests that medical staff should implement structured teamwork and communication training in a healthcare setting to impact medication administration safety positively.
Melnyk, B. M., Tan, A., Hsieh, A. P., Gawlik, K., Arslanian-Engoren, C., Braun, L. T. & Wilbur, J. (2021). Critical care nurses’ physical and mental health, worksite wellness support, and medical errors. American Journal of Critical Care, 30(3), 176-184.
This article states that the overall mental health of nurses may result in medical errors. Hospital leaders must prioritize checking the nurses’ health and provide evidence-based wellness to resolve system issues related to medication errors. The article is important to medical staff as it gives insight into nurses’ challenges that can result in medication administration errors. The article is useful in solving medication errors attributed to issues such as fatigue and stress because it suggests support to solve such issues. Ensuring nurses have proper mental and physical health will help reduce medication errors.
Training to Improve Competencies and Skills
Salami, I. (2018). Nursing students’ medication errors and adherence to medication best practice. Open Journal of Nursing, 08(05), 281- 291.
The article suggests that it is vital to train nursing students and equip them with educational tools to reduce medication administration errors. The article is useful for having the necessary knowledge and skills to prevent medication administration errors. This article emphasizes the importance of training nurses and their role in patient safety, as they are expected to ensure they have relevant skills. Training medical staff is crucial to preventing medication administration errors and associated risks.
Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian Journal of Critical Care Medicine: Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 22(5), 346.
The paper aims to describe elements of a nurse’s knowledge, behavior, and training needed to prevent medication errors, especially in the emergency department during medication administration. The article advises on the importance of teaching about medication administration to improve knowledge and coaching of new nurses to reduce errors. The article educates nurses that appropriate knowledge, attitude, and behavior influence the effective preparation and administration of medication. The nurses have to update their knowledge regularly to be up to date with new medications developed daily. This article is significant in the importance of training to increase competencies and skills.
Royce, C. S., Hayes, M. M., & Schwartzstein, R. M. (2019). Teaching critical thinking: A case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Academic Medicine, 94(2), 187-194.
Diagnostics errors are one of the factors responsible for most medication errors. Prevention of diagnostic errors requires the understanding of critical thinking by the nurses. The process requires clinical reasoning and cognitive processes in which diagnoses are made. It is important for the nurses to be equipped with these skills entailing clinical reasoning, and be imperative to identify how errors are made. The article educates nurses about their role in acquiring appropriate skills and using evident-based strategies to decrease errors and harm to patients. The paper is significant in addressing the impact of critical thinking skills on nurses to reduce medication errors.
Collaboration Strategies
Govindarajan, R., Kaur, H., & Yelam, A. (2019). Tools and strategies for quality improvement and patient safety: A Primer for Healthcare Providers. In Improving Patient Safety (pp. 263-273). Productivity Press.
The report’s author emphasizes the significance of strong cooperation from medical administration authorities. The motivation and involvement needed to push the improvement plans to physical and verbal implementation are critical to the success of the safety improvement plan. The article is relevant to situations requiring the hospital staff to ensure they have appropriate equipment and resources to prevent medication errors. The hospital board must implement safety regulations and commitment. An organization’s leaders must guarantee that sufficient finances are available to test, acquire, and train cutting-edge technology to meet the demand for resources. This source informs nurses of the need to emphasize the importance of support from the authority to counter the challenge of medication errors.
Sommer, H., & Dwenger, A. (2018). Action plan of the Federal Ministry of Health for improvement of medication safety in Germany: An inventory. Federal Health Gazette, Health Research, Health Protection, 61(9), 1062-1065.
The authors emphasize the federal government’s support for reform measures to eliminate medical errors. The paper emphasizes the need to engage political decision-makers and patient associations participating in reform efforts and administrative bodies in hospitals and other healthcare institutions. This article educates medical staff about legally obligatory implementation requirements to safeguard these action plans. The resources essential to improve medical safety are readily available because of the government’s aid. The article is useful in ensuring the medical staff work together with other stakeholders to prevent medication errors.
Herzberg, S., Hansen, M., Schoonover, A., Skarica, B., McNulty, J., Harrod, T. & Guise, J. M. (2019). Association between measured teamwork and medical errors: An observational study of prehospital care in the USA. BMJ Open, 9(10), e025314.
This source examines the relationship between measured teamwork and events of medical errors. Non-clinical skills such as leadership and teamwork are important in creating awareness and decision-making practices that lead to clinical success in reducing medication errors. The article is useful in encouraging teamwork to enhance communication, role responsibilities, decision-making, and situational awareness of patient safety practices in medication administration. The study encourages medical staff to embrace teamwork to reduce medication administration error risks effectively.
References
Al Mardawi, G. H., Rajendram, R., Alowesie, S. M., & Alkatheri, M. (2021). Reducing nonsentinel harm events due to medication errors by using mini–root cause analysis and action. Global Journal on Quality and Safety in Healthcare, 4(1), 27-43.
Connelly, D. (2019). Medication errors: Where do they happen? The Pharmaceutical Journal.
Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian Journal of Critical Care Medicine: Peer-Reviewed, official Publication of Indian Society of Critical Care Medicine, 22(5), 346.
Herzberg, S., Hansen, M., Schoonover, A., Skarica, B., McNulty, J., Harrod, T., & Guise, J. M. (2019). Association between measured teamwork and medical errors: An observational study of prehospital care in the USA. BMJ Open, 9(10), e025314.
Govindarajan, R., Kaur, H., & Yelam, A. (2019). Tools and strategies for quality improvement and patient safety: A primer for healthcare providers. In Improving patient safety (pp. 263-273). Productivity Press.
Melnyk, B. M., Tan, A., Hsieh, A. P., Gawlik, K., Arslanian-Engoren, C., Braun, L. T. & Wilbur, J. (2021). Critical care nurses’ physical and mental health, worksite wellness support, and medical errors. American Journal of Critical Care, 30(3), 176-184.
Morrison, M., Cope, V., & Murray, M. (2018). The underreporting of medication errors: a retrospective and comparative root causes analysis in an acute mental health unit over a 3‐year period. International Journal of Mental Health Nursing, 27(6), 1719-1728.
Parker, A. L., Forsythe, L. L., & Kohlmorgen, I. K. (2019). TeamSTEPPS®: An evidence‐based approach to reduce clinical errors threatening safety in outpatient settings: An integrative review. Journal of Healthcare Risk Management, 38(4), 19-31.
Royce, C. S., Hayes, M. M., & Schwartzstein, R. M. (2019). Teaching critical thinking: A case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Academic Medicine, 94(2), 187-194.
Sabone, M., Tshiamo, W. B., & Kgatlwane, J. (2020). A Mixed-methods approach to investigating medication errors. SAGE Publications Ltd.
Salami, I. (2018). Nursing students’ medication errors and adherence to medication best practice. Open Journal of Nursing, 08(05), 281- 291.
Sommer, H., & Dwenger, A. (2018). Action plan of the Federal Ministry of Health for improvement of medication safety in Germany: An inventory. Federal Health Gazette, Health Research, Health Protection, 61(9), 1062-1065.