Medication administration is a high-risk yet core function in the healthcare setting. The process requires precision and excellent communication skills by the hospital staff. Preventable medical errors harm millions of citizens annually. A medical error is defined as an act of commission or omission in the planning and/or execution of a medication procedure or process that contributes to an unintended result. Notably, it is estimated that two-thirds of all medication errors reported in healthcare facilities can be prevented. The rising concerns of patient safety in hospitals are prompting healthcare facilities to implement various strategies for detecting and reporting medication errors. Currently, many errors go undetected and unreported, making it a real challenge to assess the effectiveness of the strategies put in place to enhance patient safety. As a tool for practice development (PD), this report advocates for the use of Assess-ERRTM in hospitals to address the challenge of medication errors.
Part I: Chosen Tool and Issues Experienced
Issues Experienced in My Workplace
Most medical issues are universal, many of which require evidence-based practices to deal with. One of the most common yet prevalent problem in healthcare is patient safety (Wheeler et al., 2018). According to research conducted in 2013 by the Journal of Patient Safety, the number of fatalities caused by medical errors ranged from 210,000 to 440,000 (Makary & Daniel, 2016). Globally, medical errors have become a significant public health issue as they pose a serious threat to patient safety (Bates & Singh, 2018). As a result, reducing medical errors has become an international concern to healthcare providers.
At my workplace, the problem of medical errors has been a serious healthcare concern for years. There have been various cases of healthcare providers choosing inappropriate methods of care or executing improper methods of care delivery. Making the problem even more complicated is the fact that most of these errors go undetected and unreported (Khalifa, 2017). Often, healthcare providers do not advise their colleagues or the management when errors occur. Similarly, there is no openness regarding investigations conducted as far as medical errors are concerned. As a result, similar mistakes occur regularly and in different settings, hence rendering the safety of patients in jeopardy.
Many clinical mistakes that occur in my workplace can be prevented if adequate staff awareness and effective strategies are implemented. However, without reporting the errors, the adoption of correct strategies cannot be fostered (Car et al., 2016). The problem can be solved if every medical staff reports errors occurring in every clinical setting. However, the lack of a proper channel for reporting clinical errors is a huge barrier to dealing with the problem (Singer & Vogus, 2013). According to Poorolajal et al. (2015), hospitals that focus on improving patient safety by reducing or completely eliminating medication errors must utilize a tool for detecting and reporting such errors when they occur. Such actions will enable healthcare facilities to implement and evaluate strategies put in place to promote patient safety.
The Chosen Tool
To address the issue of medication errors in the hospital, the Assess-ERRTM tool is the most effective tool. A three-step worksheet designed to assist medical staff with medical error investigations is used (ISMP, 2011). Healthcare facilities can use the tool to record medical errors, near-miss situations, and hazardous conditions that pose a threat to patient safety. The tool can address medication errors such as assigning wrong drugs, inappropriate use of medical devices, and arithmetic errors.
Hospitals can use the tool to convert identified medical mistakes into learning experiences that contribute to enhanced patient safety. The tool helps hospitals to develop a standardized approach to documenting errors and incidents (McCormack & McCance, 2016). Similarly, the tool helps healthcare providers to discover any underlying system deficiencies that have the potential of causing or contributing to a medical error (dos Santos et al., 2018). Once healthcare staff identifies a certain problem using the Assess-ERRTM tool, various strategies can be implemented to derive the best course of action.
The Assess-ERRTM tool also helps raise awareness on common issues that are no longer regarded as health hazards. As such, the healthcare staff will shift their attention to issues that pose a serious threat to patient safety (Volpe et al., 2016). The medication system worksheet records the date of the error, the date the information was submitted, the age of the patient, and the drugs involved in the medication error. The worksheet also records the error number, which acts as a unique identifier (Tong et al., 2017). The first step of the tool addresses key issues, such as whether the error reached the patient and whether a prescriber was notified of the incident. Similarly, a brief description of the events is provided. The second step highlights the possible causes of the error. In the third step, the most effective and appropriate intervention is selected by referring to the recommendations chart. Through the three steps, healthcare facilities can implement a system-wide improvement strategy by identifying a medical error or underlying patient safety hazard, thereby implementing strategies that address the issue.
Part II: Tool Implementation
Nine fundamental principles that describe the theoretical, philosophical, and practical factors that underline practice development exist. Key among them is principle number 9 that calls for inclusivity, participation, and collaboration in approaches to PD (Bradd et al., 2017). The implementation of the Assess-ERRTM tool follows the underpinning guidelines of this principle. The process of implementing the tool in my workplace will, therefore, be a multi-process involving all stakeholders throughout each step. According to McCormack et al., (2013), nurses are pivotal to healthcare development. As a result, all healthcare staff will be given an opportunity to participate in the process by articulating ideas and providing necessary suggestions. To ensure smooth implementation, a collaboration between stakeholders, especially the hospital leadership and management, will be paramount.
Intended Goals and Objectives
Primary Goal. The primary goal that the Assess-ERRTM tool seeks to achieve is to eliminate medical errors, hence promoting patient safety by helping those involved in care provision to learn about potential health hazards, actual errors, causes of errors, and ways of preventing recurrent incidents. The tool will help the organization report errors when they occur and suggest possible strategies of preventing re-occurrence (Horn, 2016). To achieve the primary goal as the end result, the process has been broken down into both short and long-term strategic objectives.
Short-term goals. These goals are expected to be met within a period of 6-12 months after the tool has been implemented. The following are the short-term goals that the tool expects to meet;
- Create awareness among all nursing staff on the importance of reporting errors immediately upon their occurrence. Nurses and pharmacists should be aware of the necessity to adhere to both voluntary and mandatory systems of reporting errors.
- Promoting self-reporting of medical errors, where medical staff will not feel guilty or incompetent when errors occur, but rather see the need to report the errors as a way of improving patient safety.
- Creating a favorable environment for error reporting, where everyone feels free to share incidents with colleagues and supervisors
- Promoting an enabling environment where all medical staff knows the protocols and procedures in place for reporting errors. The Assess-ERRTM tool will be the most accessible and easy-to-use tool for promoting error reporting and prevention in the hospital
Long-term goals. The short-term goals are geared towards realizing the long-term objectives of the tool implementation, which is interlinked with the tool’s primary objective. The long-term goals of the tool include;
- Ability of the healthcare staff to highlight healthcare hazards as they relate to medication use, including adverse drug events (ADE), medication errors, near-misses, and close calls.
- Timely and accurate reporting of all medical errors and incidents that happen at the hospital
- Accurate identification of root causes of errors
- Zero re-occurrence of medical errors and adverse patient and drug events
- Implementation of proper strategies of addressing medical errors, which will be signaled by the zero re-occurrence of adverse incidents
- Overall improvement in patient safety, consequently making the hospital a preferred healthcare facility of choice
People Involved in the Tool Implementation Process
Seamless implementation of the Assess-ERRTM tool requires the collaboration and participation of all stakeholders. Key players involved in the implementation plan include; the administration leadership, clinical safety leadership team, hospital governance, physicians, nurses, information technology personnel, pharmacists, communication experts, and patients (Polnariev, 2014). The hospital management will ensure that the necessary resources required throughout the implementation process are availed. Similarly, a hospital’s leadership approves the project, thus making them a focal point to the successful implementation of the plan (Jordan et al., 2017). Since the technical team will be interacting with the tool on a daily basis, their involvement during the implementation process is vital to the achievement of the set objectives.
Implementation and Action Plan
Communication is an important factor when fostering any tool or process implementation in the healthcare system. The first step, therefore, entails communicating to the stakeholders, especially the medical staff, on the tool, intended objectives, and what will be required of them. To initiate the process, a meeting will be held in which key information will be laid out. The meeting will act as a good platform for group preparation. After initial communication plans have been laid out, and the hospital leadership approves the implementation of the Assess-ERRTM tool, the next step will be actualizing the implementation plan.
The implementation plan will involve a rigorous training program that will be done in phases. The training will be conducted for a period of 4 weeks, with classes and presentations taking 3-hour sessions every day from Monday to Friday. To ensure that operations run smoothly during the process, the training will be conducted in shifts, whereby hospital staff will be divided into groups depending on their work responsibilities. The first phase of the training will focus on identifying and learning the current status of the hospital with regard to error-reporting protocols. This will make the participants appreciate the current gaps in error detection and reporting, as well as the subsequent risks that such gaps pose to patient safety (Polnariev, 2016). This phase will run for 3 days, with 3-hour sessions. The second phase will involve the actual training on the Assess-ERRTM as a tool for promoting error reporting and prevention in the hospital. Medical errors that have occurred in the hospital within the last 5 years will be reviewed first. Within the first week, the three-step worksheet will be discussed in detail. Participants will be taught about various medical errors and events that can occur in a hospital. They will be guided on how to use the tool to report them. During the second and third weeks, practical use of the tool will be fostered whereby the medical staff will fill the forms as they work. The last week will involve assessments and the identification of areas of improvement. Thereafter, the tool will be rolled out for adoption in the hospital.
Evaluating whether the Assess-ERRTM tool in achieving its objectives is important. The evaluation will highlight areas of improvement, weaknesses in implementation, and areas of strength where the organizations need to focus on (Sharbafchi-Zadeh et al., 2017). Evaluation will be done based on the set goals, that is, both the short and long term. To ensure corrective actions are taken immediately for improved performance, the evaluation will be conducted weekly. Evaluation will be two-fold whereby the successful implementation will be signaled by a reduced number of medical errors and increased reporting rate. The weekly reported incidents will be recorded and a comparison made. Strategies and actions taken after the incident has occurred will be evaluated depending on the re-occurrence rate of adverse events. Table 1 below will be used to evaluate the tool.
Table 1: Tool evaluation template
|Performance Measure||Week 1||Week 2||Week3||Week 4||Week 5|
|Number of Errors Reported|
|Voluntary errors reported|
|Mandatory errors reported|
|Errors occurring more than once|
|Average days after error is reported|
|Average days after corrective action is taken|
With increasingly complex technology being introduced in medical systems annually, the problem of medical errors in hospitals may worsen if the necessary steps are not taken to curb the issue. At my workplace, medical errors pose a serious threat to patient safety. The Assess-ERRTM tool has been chosen as the most effective tool for addressing the problem of medical errors in the facility. Hospitals can use the tool to convert identified medical mistakes into learning experiences that contribute to enhanced patient safety. The primary goal of the tool is to eliminate medical errors by helping those involved to uncover potential health hazards, actual errors, causes of errors, and ways of preventing recurrent incidents. Seamless implementation of the Assess-ERRTM tool requires the collaboration and participation of all stakeholders. An evaluation of the tool will highlight areas of improvement, weaknesses in implementation, and areas of strength where the organization needs to focus on.
Bates, D. W., & Singh, H. (2018). Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736-1743. https://www.researchgate.net/publication/328752895_Two_Decades_Since_To_Err_Is_Human_An_Assessment_Of_Progress_And_Emerging_Priorities_In_Patient_Safety
Bradd, P., Travaglia, J., & Hayen, A. (2017). Practice development and allied health–a review of the literature. International Practice Development Journal, 7(2). https://www.fons.org/Resources/Documents/Journal/Vol7No2/IPDJ_0702_07.pdf
Car, L. T., Papachristou, N., Gallagher, J., Samra, R., Wazny, K., El-Khatib, M., … & Rudan, I. (2016). Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study. BMC family practice, 17(1), 160. https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0552-6
dos Santos, H. D., Ulbrich, A. H. D., Woloszyn, V., & Vieira, R. (2018). DDC-outlier: preventing medication errors using unsupervised learning. IEEE journal of biomedical and health informatics, 23(2), 874-881. https://www.researchgate.net/profile/Vinicius_Woloszyn/publication/324574946_DDC-Outlier_Preventing_Medication_Errors_Using_Unsupervised_Learning/links/5b8d6202299bf114b7ef1052/DDC-Outlier-Preventing-Medication-Errors-Using-Unsupervised-Learning.pdf
Horn, D. (2016). Importance of a CQI program in ambulatory practice. American Pharmacists Association. http://elearning.pharmacist.com/Files/Org/891a6284d25f43edab1443c43926d07c/LearningProduct/075_NE_11.pdf
ISMP. (2011). Assess-ERR™ Medication System Worksheets. Institute for Safe Medication Practices. https://www.ismp.org/resources/assess-err-worksheets
Jordan, R., Lam, J., Lyren, A., Sims, N., & Yang, C. (2017). Actionable Patient Safety Solution (APSS)# 3A: Medication Errors. Chapman University Chapman University Digital Common. https://digitalcommons.chapman.edu/cgi/viewcontent.cgi?article=1459&context=pharmacy_articles
Khalifa, M. (2017, August). Perceived Benefits of Implementing and Using Hospital Information Systems and Electronic Medical Records. In ICIMTH (pp. 165-168). https://d1wqtxts1xzle7.cloudfront.net/54648738/Perceived_Benefits_of_Implementing_and_Using_HIS_and_EMRs.pdf?1507376875=&response-content-disposition=inline%3B+filename%3DPerceived_Benefits_of_Implementing_and_U.pdf&Expires=1596229363&Signature=ZpB3GRr8BirzyN0k4jYSmR77I4HlXmUlGP4hGl~EZIeSRIkCXELcEuktd5nbzZZhlbgft5vxO4-0IRBYFMSgF1bdx9Poog9fDjk9UKkcTpcWhDqNInaggqkc~G-py9y5dy1IhelQYmYqscPlQFnMtFpLxL4zMJSwD4n2I8QMt1AKEyF~B6BbJBKcmArCYo576~4z-io-t~w8cJHRu-VHaEk4Q4x6f3SsGL8GDuUflViRz39fB6mxxrntWxKO0qgVQ3K7IfJ6gOXYpulpG8~ZXU7mBCCPkjCFyIsjURD4FwraMa~9hkMbVuZqo2sub0xzj1weZ148WfQP3ook7~9Wmw__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA
Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. Bmj, 353. https://www.bmj.com/content/353/bmj.i2139/rr-49
McCormack, B., & McCance, T. (Eds.). (2016). Person-centred practice in nursing and health care: theory and practice. John Wiley & Sons. https://books.google.co.ke/books?hl=en&lr=&id=o8pJDAAAQBAJ&oi=fnd&pg=PR9&dq=McCormack,+B.,+%26+McCance,+T.+(2016).+Person-Centred+Practice+in+Nursing+and+Health+Care+:+Theory+and+Practice.+Newark,+UNITED+KINGDOM:+John+Wiley+%26+Sons,+Incorporated.&ots=PJdJR0pF1Z&sig=WeoxM86JS3tLmHk-kN94uEWQKXE&redir_esc=y#v=onepage&q&f=false
McCormack, B., Manley, K., & Titchen, A. (Eds.). (2013). Practice development in nursing and healthcare. John Wiley & Sons. https://books.google.co.ke/books?hl=en&lr=&id=MUqG9VHyQfIC&oi=fnd&pg=PA1991&dq=practice+development+in+nursing&ots=AT9_52dtiN&sig=L8aOFS6IPq7hVf4dYvsI-tsMrLY&redir_esc=y#v=onepage&q=practice%20development%20in%20nursing&f=false
Polnariev, A. (2014). The Medication Error Prioritization System (MEPS): a novel tool in medication safety. Pharmacy and Therapeutics, 39(6), 443. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103718/#:~:text=The%20Institute%20for%20Safe%20Medication,care%20professionals%20through%20its%20publications.
Polnariev, A. (2016). Using the Medication Error Prioritization System To Improve Patient Safety. Pharmacy and Therapeutics, 41(1), 54. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699487/
Poorolajal, J., Rezaie, S., & Aghighi, N. (2015). Barriers to medical error reporting. International journal of preventive medicine, 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4629296/
Sharbafchi-Zadeh, N., Karimi, S., Molavi Taleghani, Y., & Vejdani, M. (2017). Developing an error reporting system for health centers. Journal of Patient Safety & Quality Improvement, 5(4), 606-615. https://www.researchgate.net/profile/Marjan_Vejdani2/publication/343017656_Developing_an_Error_Reporting_System_for_Health_Centers/links/5f11b1dfa6fdcc3ed70ed3ae/Developing-an-Error-Reporting-System-for-Health-Centers.pdf
Singer, S. J., & Vogus, T. J. (2013). Reducing hospital errors: interventions that build a safety culture. Annual review of public health, 34, 373-396. https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031912-114439
Tong, E. Y., Roman, C. P., Mitra, B., Yip, G. S., Gibbs, H., Newnham, H. H., … & Dooley, M. J. (2017). Reducing medication errors in hospital discharge summaries: a randomized controlled trial. Medical Journal of Australia, 206(1), 36-39. https://www.mja.com.au/system/files/issues/206_01/10.5694mja16.00628.pdf
Volpe, C. R. G., Melo, E. M. M. D., Aguiar, L. B. D., Pinho, D. L. M., & Stival, M. M. (2016). Risk factors for medication errors in the electronic and manual prescription. Revista latino-americana de enfermagem, 24. https://www.scielo.br/scielo.php?pid=S0104-11692016000100369&script=sci_arttext
Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business. Australian prescriber, 41(3), 73. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003014/