Description
Describe the health care problem or issue you selected for use in Assessment 2 and provide details about it.
Explore your chosen topic. For this, you should use the first four steps of the Socratic Problem-Solving Approach to aid your critical thinking. This approach was introduced in Assessment 2.
Identify possible causes for the problem or issue.
Use scholarly information to describe and explain the health care problem or issue and identify possible causes for it.
Identify at least three scholarly or academic peer-reviewed journal articles about the topic.
You may find the How Do I Find Peer-Reviewed Articles? library guide helpful in locating appropriate references.
You may use articles you found while working on Assessment 2 or you may search the Capella library for other articles.
You may find the applicable Undergraduate Library Research Guide helpful in your search.
Review the Think Critically About Source Quality to help you complete the following:
Assess the credibility of the information sources.
Assess the relevance of the information sources.
Analyze the health care problem or issue.
Describe the setting or context for the problem or issue.
Describe why the problem or issue is important to you.
Identify groups of people affected by the problem or issue.
Provide examples that support your analysis of the problem or issue.
Discuss potential solutions for the health care problem or issue.
Describe what would be required to implement a solution.
Describe potential consequences of ignoring the problem or issue.
Provide the pros and cons for one of the solutions you are proposing.
Explain the ethical principles (Beneficence, Nonmaleficence, Autonomy, and Justice) if potential solution was implemented.
Describe what would be necessary to implement the proposed solution.
Explain the ethical principles that need to be considered (Beneficence, Nonmaleficence, Autonomy, and Justice) if the potential solution was implemented.
Provide examples from the literature to support the points you are making
The following resources provide information about evidence-based practice:
Macias, C. G., Loveless, J. N., Jackson, A. N., & Srinivasan, S. (2017). Delivering value through evidence-based practice. Clinical Pediatric Emergency Medicine, 18(2), 89–97.
Thomas, S. J. (2016). Does evidence-based health care have room for the self? Journal of Evaluation in Clinical Practice, 22(4), 502–508.
Agency for Healthcare Research and Quality. (n.d.). EPC evidence-based reports. http://www.ahrq.gov/research/findings/evidence-bas…
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Analyze a Current Health Care Problem or Issue
Learner’s Name
Capella University
NHS4000: Developing a Health Care Perspective
Instructor Name
August, 2020
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2
Analyze a Current Health Care Problem or Issue
Patient safety, as discussed in the previous assessment, is an important element of quality
health care. This assessment will expand upon patient safety issues that occur when patients are
exposed to inadvertent harm or injury while receiving medical care. Health care organizations
should maintain and develop a safety culture to prevent patient safety issues. Patient safety
culture is defined as a system that promotes safety by shared organizational values of what is
important and beliefs about how things work. It also encompasses how these values and beliefs
interact with the work unit, organizational structures, and systems to produce behavioral norms
(Ulrich & Kear, 2014). As such, care should be taken to improve the infrastructure of health care
organizations. Improving patient safety should be discussed and addressed by every individual
associated with public health care.
Elements of the Problem/Issue
Research shows that while getting treated at health care organizations, patients might be
at risk of experiencing the harm or injuries associated with medical care. The most likely causes
of patient safety issues are preventable adverse events, which are adverse events attributable to
error. These errors can be classified as diagnostic errors, contextual errors, and communication
errors (Ulrich & Kear, 2014).
Diagnostic errors take place when health care professionals provide a wrong or delayed
diagnosis or no diagnosis at all (James, 2013). An example of a wrong diagnosis is a health care
professional diagnosing a patient with gastric troubles when the patient is actually experiencing a
heart attack. An example of a delayed diagnosis is a patient not being notified of an abnormal
chest X-ray, thereby delaying diagnosis of a serious medical condition. An example of a missed
diagnosis is a patient not being diagnosed with heart failure despite warning symptoms.
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Contextual errors occur when health care professionals fail to consider their patients’
personal or psychological limitations while planning appropriate care for them. An example is a
health care professional’s failure to recognize that basic follow-up discharge instructions may not
be understood by patients with cognitive disabilities (James, 2013). It is important for health care
professionals to be aware of their patients’ mental and physical abilities before they formulate a
plan of care.
Communication errors occur when there is miscommunication or lack of communication
between health care professionals and patients (James, 2013). They can cause severe harm to
patients. An example of this is a nurse failing to tell a surgeon that a patient experienced
abdominal pain and had a drop in red blood cell count after an operation, resulting in the death of
the patient due to severe internal bleeding. Limited health care knowledge; language barriers;
and auditory, visual, and speech disabilities could also lead to communication errors and cause
safety issues.
Analysis
As a medical transcriptionist, it is important for me to be aware of potential transcription
errors and privacy standards, which affect patient safety. Errors like these pose dangerous risks;
therefore, it is necessary to have an overall quality evaluation of the transcribed documents.
Also, I must ensure that serious difficulties in transcription resulting from poor-quality voice
files are reported immediately to the manager, who will then convey this to the health care
professionals involved in the process. This will help ensure that patient safety is not
compromised.
Context for Patient Safety Issues
With the advancement of medical technology, health care processes have become
extremely complex. Health care professionals are required to stay up to date with a lot of new
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knowledge and innovations obtained from research. This often overburdens them as there is a
need to apply the learning from research in their practice. Also, at the individual level, there is a
dearth of well-balanced continuing education programs, which has resulted in a lack of attention
to patient safety among health care professionals. At the system level, organizations fail to
deliver optimum health care as a result of being understaffed, an inability to provide appropriate
technology, and ineffective execution of patient care transfer (James, 2013). Overcrowding and
understaffing delays initiation of treatment and puts critically ill patients at significant risk. All
of these factors contribute to a rise in patient safety issues.
Populations Affected by Patient Safety Issues
Patients with a psychiatric history are also a vulnerable group of people who face patient
safety issues because their psychiatric records are often combined with their current symptoms.
Patients with a documented history of psychiatric illness may avoid seeking health care services as
they feel that their care will be based on their past record of illnesses and not their present needs.
Therefore, psychotherapists should implement measures such that their psychiatric data is concealed
from their medical records before it is shared with the third party, which helps protect patients’
confidentiality (Shenoy & Appel, 2017).
Considering Options
Patient safety in hospitals can be achieved by creating a culture of safety that involves
effective communication, correct managerial leadership styles, and the use of Electronic Health
Records (EHRs). Effective communication while passing patient-specific information from one
health care professional to another is essential in ensuring continuous and safe patient care.
Training the team could likely improve consistent successful communication and help prevent
errors. Standardizing critical content that needs to be communicated by the initial health care
professional ensures safe transfer of care (Farmer, 2016).
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It is essential for leadership teams to adopt organizational strategies that would improve
patient safety and transform their organizations into reliable systems for enhanced patient
satisfaction. They should set strategic safety goals, which could include adhering to standards of
health, assessing quality, using patient satisfaction reviews, and analyzing adverse event reports
to determine improvement in safety issues (Parand et al., 2014).
An EHR is another potential solution to prevent patient safety issues. It is a digital record
of a patient’s medical information that includes history, physical examination, investigations, and
treatment (Ozair et al., 2015). It helps manage multiple processes in the complex health care
system and prevents errors. EHRs utilize less storage space compared to paper documentation
and allow an infinite number of records to be stored. In addition to being cost-effective and
preventing a loss of records, EHRs help conduct research activities and provide quick data
transfer (Ozair et al., 2015).
Solution
In health care, because transmission of information takes place among different people
and electronic devices, there is a high likelihood of errors occurring. For example, transcription
errors (which occur due to poor audio quality or the lack of a quality evaluation process) can be
prevented by using recording equipment with good sound quality and by maintaining
proofreading and quality checks. However, integrating transcription processes with the HER
system helps prevent errors, helps access the required information faster, and allows health care
professionals to take accurate decisions about patients’ care.
Implementation
An EHR is an important mechanism for improving patient safety. Its advancement has
made it a viable option to prevent medical errors. However, the use of EHRs has certain ethical
implications such as security violation, data inaccuracies, lack of privacy and confidentiality, and
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challenges during system implementation. Security violation takes place when patients’
confidential health information is accessible to others without their permission. To avoid security
violation, data should not only be password protected but also encrypted to restrict access to
unauthorized individuals. Firewalls and antivirus software should be used to protect data (Ozair
et al., 2015).
Though EHRs improve patient safety by reducing medical errors, data inaccuracies are
increasing. Loss of data during data transfer leads to inaccuracies that affect decision-making
related to patient care. A problem of concern related to data inaccuracy is medical identity theft,
which leads to incorrect information being filed into a person’s medical record, which in turn
leads to insurance fraud and wrong billing (Ozair et al., 2015).
In health care, information that is shared during physician–patient interactions should be
kept confidential and should be made inaccessible to unauthorized individuals. Enabling rolebased access controls based on user credentials will restrict access to the EHR system to
authorized users. The user should also be made aware that he or she is responsible for any
information that he or she misuses (Ozair et al., 2015).
As EHR is a complex software, there is a high likelihood that software failure may result
in inaccurate recordings of patients’ data. Therefore, EHR system implementation may have
ethical implications due to the violation of data integrity (Ozair et al., 2015). EHRs can safeguard
patient confidentiality by using various methods that prevent security breaches. In addition to
this, creating reminders that ask for a confirmation before accessing confidential information can
help protect data. A nesting system could be developed, which would allow, for example, a
health care professional from a specific specialty clinic to access patient records by signing into
the specialty domain (Shenoy & Appel, 2017). These methods will enable the safe and efficient
use of EHRs and ensure patient safety.
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Conclusion
Patient safety involves preventing the risk of harm or injuries to patients by establishing a
safety culture and providing high-quality medical care. Health care organizations must
understand patient safety issues and find solutions for these issues by designing systems that
prevent errors from occurring. Potential solutions include effective communication, changes in
leadership style, and the use of EHRs. The ethical implications of these solutions should be
considered before implementing them in a health care setting. It is also important that health care
professionals undergo continuous education and effective training, provide appropriate medical
care, prevent errors, and follow safety practices to improve clinical outcomes.
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References
Farmer, B. M. (2016). Patient safety in the emergency department. Emergency Medicine, 48(9),
396–404. https://mdedge.com/emed-journal/article/113659/trauma/patient-safetyemergency-department
Flood, B. (2017). Safety of people with intellectual disabilities in hospital. What can the hospital
pharmacist do to improve quality of care? Pharmacy, 5(3).
https://ncbi.nlm.nih.gov/pmc/articles/PMC5622356/
James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital
care. Journal of Patient Safety, 9(3), 122–128.
http://dx.doi.org/10.1097/PTS.0b013e3182948a69
Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health
records: A general overview. Perspectives in Clinical Research, 6(2), 73–76.
http://dx.doi.org/10.4103/2229-3485.153997
Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality
and patient safety: A systematic review. BMJ Open, 4(9).
http://dx.doi.org/10.1136/bmjopen-2014-005055
Shenoy, A., & Appel, J. M. (2017, April). Safeguarding confidentiality in electronic health
records. Cambridge Quarterly of Healthcare Ethics, 26(2), 337–341. https://searchproquest-com.library.capella.edu/docview/1882434628?pqorigsite=summon&https://library.capella.edu/login?url=accountid=27965
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent
health care delivery. Nephrology Nursing Journal, 41(5), 447–456, 505. https://searchproquest-
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com.library.capella.edu/docview/1617932572/fulltextPDF/1486CC30B3624B3CPQ/1?ac
countid=27965
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Analyzing a Current Health Care Problem or Issue
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Analyzing a Current Health Care Problem or Issue
Makeiah Karmea Bynum
Capella University
NHS-FPX4000: Developing a Healthcare Perspective
Instructor: Dr. Joan Vermillion
April 10, 2023
Analyzing a Current Health Care Problem or Issue
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Applying Ethical Principles
It is impossible to overestimate the significance of pharmaceutical errors in healthcare,
which I have already mentioned. In this investigation, concerns about patient safety that
unintentionally occur when getting medications will be explored upon. Healthcare providers
should take all reasonable precautions to ensure patient safety. Patient safety should be promoted
in all facets of healthcare. If nurses were able to implement a culture where drug errors were a top
priority, it would be a significant step in preventing those errors from frequently occurring.
Everyone involved in the healthcare system should discuss how to make it better. Improved
infrastructure would also be a big help in resolving this issue. Pharmaceutical errors do not only
happen in hospitals. Medication mistakes may accompany the patient back to their home or
nursing home (Fatima, Douglas & Richard, 2020).
Elements of the Problem/Issue
Studies show that patients receiving care from hospital medical professionals are
susceptible to drug mistakes and potential harm. Patient safety issues are typically caused by
medication errors, which are preventable adverse outcomes (Albara, Suzanne, Joanne, & Val,
2020). Medication errors can be caused by three main sources: not understanding the directions,
fulfilling the order too swiftly, and communicating with other healthcare professionals.
When a nurse disregards her incapacity to grasp the instructions and nonetheless provides
the authorized dose, the wrong medication or the erroneous dosage may be given. A patient may
experience terrible side effects if they receive an excessive amount of one drug. For instance,
sliding-scale insulin has parameters that determine how much to provide dependent on the
Analyzing a Current Health Care Problem or Issue
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patient’s blood sugar level. If you don’t understand the parameters, you might administer too much
insulin and cause hypoglycemia in the patient (Albara, Suzanne, Joanne, & Val, 2020).
Rushing through an order to finish it can cause you to miss a mistake that the doctor might
have made. Without taking the time to read the order carefully and determine whether what was
ordered for the patient makes sense, the patient could suffer severe harm. A person who is
prescribed Lasix because their lower extremities retain fluid is an example of this. In addition to
causing them to lose vital electrolytes, which can cause a host of other problems, failing to review
the most current lab findings could force all the fluid to come off them. Therefore, the key to
avoiding a medicine blunder is to carefully read the order.
The outcomes of poor doctor-nurse communication can be disastrous. Negative outcomes
for a patient could result from failing to inform a doctor that a particular order might cause more
damage than good to a patient. A doctor prescribing MiraLAX to a patient is an illustration of
this. Because it is ordered, new nurses will provide it, even when the patient is experiencing
bowel movements. Dehydration could result from this, which can cause a diverse range of
problems. The nurse could hold the order or inform the doctor that they are using the restroom
and stop the order to prevent fluid imbalances.
Analysis
Since becoming a registered nurse, I made it a critical part of my practice to make sure I
completely understand the medication that I am administering to my patients prior to them being
given. I am the last resort in the line of defense before they can receive the medication that has
been prescribed by a medical professional. Making a mistake when administering medication or
failing to spot a mistake made within the medication order can result in serious harm to the
patient. When I am unsure about any orders or prescriptions given, I make sure to question and
Analyzing a Current Health Care Problem or Issue
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receive other people’s opinions, preferably seasoned nurses, or the provider themselves, to make
sure that I avoid making a mistake. Anyone can make a mistake. If a mistake were made, it is best
to inform the manager about the error because it can help improve strategies to prevent the error
from happening again, therefore, reducing medication error frequency.
The Context for Patient Medication Errors
Another contributing factor to patient medication errors is the constant evolution of
healthcare. It is changing constantly with daily research being done to progress medicine. As an
employee in medicine, we must make sure we are up to date on these advances in healthcare. It is
highly exhausting to learn the newest and best information that is other it. It is also a challenge to
always provide top-notch healthcare to our patients when there are staffing shortages, unsafe
assignments, and unavailable equipment that is needed to perform our duties. Any arrangement of
these factors can result in unsatisfactory healthcare and increase the likelihood of medication
errors.
Populations Affected by Patient Safety Issues
Medication errors do not have a stereotype. Any demographic group can become a victim
of a medication error. As healthcare providers, we try to notice any mistake that is made including
medication errors, but because we are human, that is not always possible. We can strive to make
as few mistakes as possible, but even then, some adverse effects can be unknown. Every shift, I
notice where an error could have been made had I not been more vigilant and paying attention to
my orders. The best way to become excellent at identifying errors and preventing harm is
knowing the medication you are attempting to give and asking questions at any point where there
Analyzing a Current Health Care Problem or Issue
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is uncertainty. Due to this, I eliminate any mistakes that might occur which prevents my patients
from suffering an avoidable injury.
Considering Options
To reduce medication errors, healthcare professionals could implement some of these
strategies. Education on carefully reviewing orders and querying the physician if an order doesn’t
seem correct is a step in preventing errors from happening. As a new grad nurse, I was always
unsure when to question a physician about an order. Now after two years, I have found that
sometimes orders get put in on the wrong patient and it was a good step that I questioned the
orders that didn’t seem to relate to my patient’s primary complaint. Another is assigning fewer
patients so that the nurse can focus on a smaller ratio. Anyone working in healthcare currently
knows that depends on staffing. Reviewing the orders that have been placed in detail is the easiest
and most obvious course of action. Taking your time and avoiding rushing through the task is a
key step in minimizing prescription error rates. The opportunity of sitting down and carefully
reading directions would lessen the likelihood of medication errors. Prescription errors would be
less likely if it was possible to sit down and attentively study orders.
Questioning a doctor when they issue an order that appears to be erroneous is one of the
hardest things to undertake. The ability to discuss it with the doctor is a key method where drug
errors could be prevented. Although incredibly intelligent, doctors are nonetheless human and fall
short just like everyone else. Because of this, it’s crucial for nurses to contact them if an
instruction seems strange. The patient could avoid injury thanks to this very little interaction. The
interaction between healthcare professionals is one element that I believe is neglected. I believe it
is crucial to note the time you administered painkillers in your report. A medication error can be
avoided by having open communication.
Analyzing a Current Health Care Problem or Issue
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Solution
It is impossible to find only one solution for the treatment of medical errors because there
is a variety of contributing factors that lead to the error occurring, which means there needs to be
a solution for every possible factor out there. Improving communication between physicians and
nurses, querying orders when clarification is needed, lowering patient ratios, and having adequate
time to carefully review orders in full detail could improve the prevention of medication errors.
As healthcare professionals, all we can do is continue in our efforts to reduce the occurrence of
drug errors.
Implementation
Every healthcare worker signed an oath before beginning their employment. One of the
most important aspects of that oath is nonmaleficence, or the duty to do no harm. The best care is
given to each patient as part of our effort to show this. Medication mistakes can be considerably
reduced by putting these changes into practice. A number of these adjustments must be made and
implemented by the person. Management is unable to use them precisely. The greatest way to
lessen prescription errors, in my opinion, is to employ these strategies.
Conclusion
Eliminating drug mistakes won’t ever be successful 100%. It is impossible to totally
eradicate drug errors because mistakes will always be made by people. On the other hand, the
implementation of some strategies discussed along with increasing healthcare professional
awareness could significantly help minimize the frequency of medication errors which in turn
would provide the patients with the best care possible. It is crucial that nurses comprehend that
Analyzing a Current Health Care Problem or Issue
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implementing these measures is not intended to make their jobs harder, but rather to safeguard
both the patient and their professional license.
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References
Alomari, A., Sheppard‐Law, S., Lewis, J., & Wilson, V. (2020, July 6). Effectiveness of Clinical
Nurses’ interventions in reducing medication errors in a paediatric ward. Journal of
Clinical Nursing, 29(17–18), 3403–3413. https://doi.org/10.1111/jocn.15374
Alqenae, F. A., Steinke, D., & Keers, R. N. (2020, March 3). Prevalence and Nature of
Medication Errors and Medication-Related Harm Following Discharge from Hospital to
Community Settings: A Systematic Review. Drug Safety, 43(6), 517–537.
https://doi.org/10.1007/s40264-020-00918-3
Athanasakis, E. (2019, June 6). A meta‐synthesis of how registered nurses make sense of their
lived experiences of medication errors. Journal of Clinical Nursing, 28(17–18), 3077–
3095. https://doi.org/10.1111/jocn.14917
Secginli, S., Nahcivan, N. O., Bahar, Z., Fernandez, R., & Lapkin, S. (2021, October 8). Nursing
Students’ Intention to Report Medication Errors. Nurse Educator, Publish Ahead of Print.
https://doi.org/10.1097/nne.0000000000001105
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