Introduction
Improvements in medical therapeutics have occasioned chief developments in the delivery of healthcare services for patients who have been diagnosed with one or more diseases, nonetheless these advantages have also been supplemented by augmentedhealth risks. A medication error commonly refers to a fault such as, omission or commission at any stage along the path that usually arises when a physician prescribes a particularmedicine (Rose et al., 2017). The pathway usually ends when the patient trulyobtains the medication. Medication errors have been found to give rise to adverse drug events (ADE) that are defined as injuryor damage to a patient, owing to the exposure to particular drug. Time and again it has been established that medicinal product refers to a substance that is anticipated to be administered to, or consumed by a person, with the aim of effectively preventing or managing a disease (Nanji et al., 2016). In other words, medication error can be defined as an avoidable event that might lead to or cause inappropriate use of medication and patient harm, while the prescribed medicine is under the control of the healthcare provider, consumer or patient. There are a plethora ofdiverse approaches that are typically followed for the classification of medication errors. One method is to base the cataloguing in the order of medicine use procedure, such as, prescription, transcription, provision, administration or observing. Another method is to contemplate the kinds of errors happening, such as,incorrect medication, frequency, dose, route of administration and wrong patient.
Time and again it has been established that some of the most common factors that are associated with medication errors in hospital are absence of necessary therapeutic training amid healthcare professionals, inadequate patient knowledge, inadequate drug knowledge, poor communication, emotional and physical health issues, fatigued healthcare staff, and lack of adequate perception of the associated risks (World Health Organization, 2016). The primary reason for selecting this topic of investigation can be accredited to the ‘Monitoring and Reducing Medication Errors in Hospitals National Conference 2019’that will highlight on the need of lowering medication errors and the resultant damage and harm caused to patients in hospitals. It was highlighted in the brochure of the conference that an estimated 237 million cases of medication error occur every year in England (Healthcare Conferences UK, 2019). In addition, it also elaborated on the need of preventing these errors with the accurate implementation of training, technology and standardised procedures.
Furthermore, recent reports from England also state that medication errors lead to as much as 700 deaths everyyear and can also be cited as a significant factor between 1,700-22,300 other ones. The report helped in identifying the fact that roughly 1.15 billion medication prescriptions are prepared each year. In addition, it also highlighted a case study where a woman, aged 92 years, who had been residing in a care home had been administered incorrect medications for numerous weeks, following a mix-up of her prescription with another patient that resulted in eye irritation (Triggle, 2018). The aforementioned findings provided an insight into the fact that medication error was not just restricted to a particular healthcare setting, but was a global issue and can create dreadful levels of injury and death that are completelyavertible. This report will present a literature review on medication error interventions and will elaborate on an improvement project for bringing about a change.
Literature Review
According to a research reports published by the NHS, it has been stated that a total of 237 million medication errors occur within the province of England and other parts of the United Kingdom (Addelman, 2019). Further, research studies also reveal that approximately 100 deaths can be prevented every year that occur on account of adverse drug reactions. In this context, it is worth noting that researchers from the prestigious universities of Sheffield and York have reported epidemiological findings that suggest approximately 712 deaths can be avoided that occur as a result of adverse drug reactions (Ashcroft et al., 2015). On an average, 1700 to 22,303 deaths take place annually due to medication errors. Medication errors results in increased economic expenditure around £ 98.5 million on yearly basis and attribute to poor care outcome for the patients (Baqir et al., 2015). Research studies further suggest that the rate of medication error is most common within emergency care unit followed by primary care unit and long term care unit (Elliot et al., 2018; Baqir et al., 2015). Medication error is expected to cause poor health outcome, increase associated healthcare cost and prolong hospital stay which can cumulatively diminish the quality of life of the patients (Ashcroft et al., 2015). In order to effectively address the problem related to medication error and poor health outcome, an exhaustive search would be conducted on the electronic databases in order to retrieve relevant research articles that can help to identify the evidence based strategies to prevent medication error and related adverse drug reactions.
Research Question
On the basis of the background research, the following research can be articulated:
What are the effective evidence based interventions that can be adapted within a clinical setting to prevent medication error and related adverse drug reactions?
Search Strategy
A rigorous search was conducted on the electronic databases of Google Scholar and PubMed using appropriate search terms in order to obtain research journals that were aligned to the research question. Grey literatures which are basically academic materials that are published by organizations apart from commercial or academic purpose were not considered for this research study. In addition to this, appropriate exclusion and inclusion criteria were used in order to obtain relevant research papers. The inclusion criteria comprised of characteristics such as consideration of research papers that were published between 2015 to 2019. In addition to this, papers that were published in English language were considered and research journals that were accessible for complete text were only considered. On the other hand, the exclusion criteria typically comprised of papers that were published in foreign languages other than English. In addition to this, papers that were not accessible for full text and papers that were published before 2015 were considered. Also, BOOLEAN operators such as OR/AND were used in combination with the search terms to obtain relevant results. The following search terms were used to conduct a search across the electronic databases:
Medication error, adverse drug reaction, poor patient outcome, prevention, interventions, positive care, improved patient outcome, quality and reduced hospitalizations
The search terms were used in combination with the BOOLEAN OPERATORS such as Medication error OR adverse drug reaction AND Prevention. The use of the BOOLEAN terms helped to obtain the most appropriate research papers that were aligned to the concept of the research question.
Upon using the search terms on the electronic databases, a total of 10 papers were retrieved. Additionally 2 more papers were identified from the Cochrane library databases. However, 5 papers were eliminated as it did not meet exclusion/inclusion criteria and lastly 7 papers were considered for the literature review. (Refer Appendix 1)
Summary of findings
Goedecke et al. (2016), stated that medication error is most likely to lead to an adverse drug reaction or an unintentional drug failure which can lead to compromised patient safety. The researchers were of the opinion that reducing risks related to medication error could help to promote positive patient outcome. In this context, the researchers stated that the process of reducing medication error and promoting increased safety was a shared responsibility that operated between the care professionals and the patients. The overall findings of the researchers suggested that integration of improved pharmacovigilance standards and medication safety standards can help to acquire improved patient outcome. Further, the researchers also suggested that the improved compliance with the EU regulatory network can help to assure improved patient safety.
Rodziewicz and Hipskind (2019), also stated that medication error has emerged to be a serious problem that compromises the overall public health and safety. The researchers are of the opinion that medication errors are basically of two types which include, errors related to omission which emerge as a result of not taking an action. On the other hand, the second category of errors arise as a result of taking incorrect actions. The example for the first kind of error can be cited as overlooking a particular dose of medication administration. On the other hand, the second category of errors would include administering incorrect medication via the wrong route or preparation of incorrect dose. Rodziewicz and Hipskind (2019) mentioned that care professionals are often subjected to a wide range of negative psychological effects such as stress, burnout or anxiety owing to the strenuous nature of the clinical environment. Further, excessive patient load and chaos within the care unit can serve as distraction and lead to medication errors. Fostering a constructive work environment free from stress and the fear of shame and guilt can help to promote positive patient outcome. Further, improved knowledge about the type of medication errors and adherence with the medication safety standards can help to ensure increased patient safety.
Charkhat et al. (2015), stated that medication errors invariably lead to compromise with patient safety and can even lead to death of the patients. The researchers conducted a cross sectional descriptive study where in a total of 327 nursing professionals were considered as participants to investigate the primary causes that led to medication errors within a clinical setting. The researchers collected data by means of questionnaire surveys and analysed the obtained results by the use of statistical interpretation. The research results suggested that the most common cause of medication error was due to increased work load (~97.8%) and incorrect drug calculation (~77.4%). Further the research findings of the researchers suggested that incorporation of mentorship and improved guidance in terms of knowledge about medication standards and side effects can help to improve overall patient safety and promote positive patient outcome.
D Schiff et al. (2017), opined that integration of an advanced computerised provider order entry can help to prevent medication errors that are related to ‘look alike sound alike’ medication orders. The researchers support their proposition with statistical data which mentions that incorporation of computerised order entry helped to improve medication safety by more than 10% to 70% within the United States of America. The proposal of the idea was to popularise the scheme of electronic ordering of medication both inside as well as outside the healthcare setting. The idea is to order the medication electronically and send the orders electronically to the pharmacy companies. This could potentially avoid the risk of committing medication errors and help to promote positive patient outcome. The researchers speculate that lack of physician’s acceptance as well as lack of a standard electronic transmission guideline can generate poor outcome. However, the overall conclusion of the researchers suggest that integration of the automated ordering system would help to reduce medication errors.
Marianne et al. (2016), conducted a pilot study to enhance the sensitivity of registered nurses to risks and improve behaviours so as to reduce observed medication errors within healthcare settings. The researchers believed that medication errors were preventable and could efficiently be improved with the integration of change within the operation and reporting system. It should be noted in this context that the researchers suggested that conducting education and awareness workshops could help to prevent medication error and contribute to positive patient outcome. Post the implementation of the education program, it was observed that nurses perception and attitude to identify medication error was significantly improved. Also, the educational program helped to improve compliance with safe medication standards and enhance patient safety. Hence, it can be mentioned that the overall findings of the researchers suggested that support strategies for safer medication practice could help to reduce the prevalence of medication errors within clinical care settings.
Foanio et al. (2017), suggested that the development and evaluation of an algorithm for the detection of common medication errors can help to prevent errors that are similar to ‘look alike sound alike’ type of drugs. The computerised algorithm is equipped with technology to identify and flag ‘look alike sound alike’ medication error by aligning the diagnosis of the disorder with the prescribed medication. The overall findings of the researchers mention that the use of automated methods for the process of medication orders can help to reduce LASA medication errors.
Miller et al. (2016) stated that most of the medication errors were on account of poor pharmacological knowledge about the Drug types and their impact on the overall health outcome of the patients. Further, the most common medication error was largely attributed to wrong route of administration. The most effective intervention to reduce medication error included, conducting education programs that stress upon the compliance with the 5 R’S of medication and improved knowledge about the use of the Universal Drug Index and the process of reviewing prescribed medication. Incorporation of educational strategies can help to acquire improved patient outcome and reduce the incidence of medication errors within a healthcare environment.
Implementation Strategy
In the rapidly altering healthcare environment, use of computer assisted devices and technological improvements can challenge all healthcare professionals in a plethora of ways. Implementation of a change in nursing practice within the healthcare environment often results in the onset of fear and anxiety regarding failure, thereby causing resistance to the changed practice (Gopee& Galloway, 2017). The evidences discussed in the previous section suggest that medication errors that commonly occur in healthcare settings trigger in the onset devastating outcomes for both the patient and the nurse. These negative outcomes can be significantly reduced through the usage of technology that advances patient care and enhances performance of the nursing professionals. Bar-coded medication administration has been identified as onecategory of technology that is based on the usage of a scanning equipment for comparing bar codes that are present on identification bands worn by patients (Larson & Lo, 2019). These bar codes generally contain information about the prescribed medications, following which they are electronically verified against the medicine records, thusdecreasing medication error events. Hence, the improvement project will be based on application of Lewin’s theory of management for successful implementation of bar-coded medication administration.
Kurt Lewin’s theory have been implemented by several healthcare organisations in order to gain a sound understanding of human behaviour, as it is associated to change management, and different patterns of resistance. According to Hussain et al. (2018) also referred to as the Lewin’s Force Field Analysis, the theory generally encompasses three separate phases namely, unfreezing, moving, and refreezing (Cummings, Bridgman & Brown, 2016). The primary intention behind implementing this model in the healthcare setting is to recognise factors that can obstructthe anticipated change from happening, forces that compete with change,frequently called restraining or those that will promote the change, mentioned as driving forces.
Application of the theory
The first step of unfreezing will involve communicating with the major stakeholders at the hospital such as, the administration, managers and frontline nursing staff. The line of communication will be kept honest and open, thus will help in establishing a sense of safety and conviction in all stakeholders. Round table discussions will be initiated at this stage with the sole intention of teasing out the restraining and driving forces (Cummings, Bridgman & Brown, 2016). While some restraining forces can be poor computer literacy, lack of faith, and aversion to new machinery, upper management support and sufficient financial investment might act as driving forces. During the moving stage, bar coding will be implemented across the healthcare facility and will necessitate the continueddetermination from numerous teams, such as,pharmacy, information technology (IT), nursing, clinical information services (CIS), clinical nurse educators, program managers, and administrators. The nursing staff will be actively involved for developing a sense of possession, regarding efficacy and attainment of the improvement of the project (Burnes&Bargal, 2017). The nurses will be trained to interpret bar coding. A project leader will be asked to monitor and oversee the project at this stage. During the final stage, continued technology support will be offered, till the change is considered complete and the patients arecontented with the machinery.
As change occurs in an organisation, it is significant to observe and assess the consequences of the change programme. This includesconnecting the changes to the innovativeplan and purpose (Batras, Duff & Smith, 2016). If change is not assessed it will be extremely problematic for the managers to explore the efficacy of bar-coding system in reducing medication error. The strategy to be used for assessing the change is key performance indicators (KPIs). These indicators will monitor how effectively the stakeholders have worked towards accomplishment of the intended objective (Hayes, 2018). Taking into consideration the fact that the objective was to reduce medication error, a clinical audit will be conducted prior to, and after implementation of the change management program. The duration of this change management will be four months. Prior to the change management, the nurses, pharmacists and physicians will be asked to participate in voluntary reporting of medication error incidents, in addition to conducting chart review. After four months, they will again be asked to perform the same procedure, following which the number of events related to medication error that occurred in the hospital during the period will be assessed. Decrease in the medication error events will confirm success of the change management program.
Evaluating change management
In the contemporary eventful and demanding healthcare environment, nursing professionals are generally anticipated to keep up with up-to-date cohesive technology, frequently with little or no say regarding their impacts. Showing consistency with any new modification, ‘buy in’ by the nurses who are in the front line is indispensable to ensure a smooth change of the informatics project, owing to the fact that several nurses can be hesitant and resistive to innovative computer aided equipment in practice. According to Amarantou et al. (2017) management of change has continuously been thought-provoking in healthcare amenities, and new machineries often provoke confrontation from nurses who by now cannot find sufficient time during their work shift for completing patient associated tasks. Numerous barriers have been recognised when applying a change in process of this scale together with non-existence of collaboration between staff, dread of using innovative methods, and confrontation to change in anticipation that the novel technology would not prove effective.
Resistance to change management
One potential barrier that could influence the application of bar-coded medication administration at the hospital is the likelihood of different patients declining to put on the identification bands, which in turn is necessary for success of the project. In addition, other barriers might comprise of shortcuts that certain nurses have implemented to save their time and energy, such as, pre-pouring of medications, which breaches the basic nursing standards of practice(Chai&Goldhirsch, 2019). This resistance can be overcome by allocating appropriate roles and responsibilities to the stakeholders that will allow them to use their expertise to the best advantage. In addition, breaking the innovation project into smaller milestone, and celebrating the accomplishments of the nurses will prove beneficial. Moreover, the seven methods of care-fronting will also be used for controlling communicative breakdowns (Endrejat et al., 2017). It is also imperative to produce an upright team spirit, while holding team bonding sessions. Creating opportunities for feedback and displaying flexibility will also help in overcoming resistance to change, thereby facilitating reduction of medication errors at the hospital.
References
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