Description
Module 07: Critical Thinking Assignment
Medical Errors – Policy and Procedures (100 points)
Reporting errors in healthcare is an essential component of patient safety.
For this assignment, you will assume that you are a healthcare administrator at a healthcare facility (Hospital, long term care facility, clinic, etc.).
You are tasked with creating a process for reporting errors and reducing adverse events at your facility. Your submission will demonstrate your knowledge of healthcare error reporting to create your process. Be sure to include at least one QI tool and discuss the process involved.
Describe how your process aligns with current practices in KSA. Include current data of medical errors in healthcare settings within KSA and describe what the current gaps are. Your process should address these gaps that are published in the literature.
Your process should include the following:
An identification of the most prevalent and common medical errors in your facility
Risks associated with those medical errors
All individuals (staff, groups, agencies) who will be involved in the reporting process
Design a reporting template and be sure to include any workflow processes or tools can be used in the process
Provide a brief evaluation of departments responsible for following up on the errors and events.
Your report should meet the following structural requirements:
Be five to six pages in length, not including the title or reference pages.
Be formatted according to APA 7th edition Saudi Electronic University writing guidelines.
Provide support for your statements with in-text citations from a minimum of six scholarly articles. Two of these sources may be from the class readings, textbook, or lectures, but four must be external.
Utilize headings to organize the content of your work.
You are strongly encouraged to submit all assignments to the Originality Check prior to submitting them to your instructor for grading.
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Medication Errors – Policy and Procedures
Saudi Electronic University
Master of Health Administration
HCM-520: Quality and Performance Imprve
Critical Thinking Assignment, Module: 07
Dr. Bryan Bermeier
G200318352
Sultan Alshehri
March 11, 2022
Introduction
Every day, medication errors occur nationwide. These errors can happen at a hospital,
long-term care facility, rehabilitation facility, or even in home health. Every year, between 7,000
and 9,000 people die from drug errors, affecting over 7 million people, costing over $40 billion
to cure (Tariq et al., 2018).
The most common medication accidents are unreported. By definition, a pharmaceutical
error is “any preventable incidence that results in drug errors that cause patient harm.” While
medications offer many benefits, misuse can bring harm.(Alshammari et al., 2021) They produce
protracted hospital stays, poor outcomes, and poor quality of life. To prevent pharmaceutical
errors, the public must be made aware of their occurrence and consequences. There are several
ways to make medication errors in hospitals.(Alshammari et al., 2021)
A medication error reporting system is essential to safeguard patients by reducing
medication errors. Using CPOE helps eliminate these errors. Intentional drug errors may increase
mortality. Thus, a safe medical environment helps reduce medication errors. To improve patient
safety and treatment quality, Saudi Arabian HCPs must know that everyone must report
medication errors. Understanding existing knowledge and practice is also required to build
specific strategies and plans to enhance them. The Saudi Central Board for Accreditation of
Healthcare Institutions (CBAHI) standards should be utilized to prevent prescription
errors.(Reporting Medical Errors, n.d.) The CBAHI is the official accrediting body for all Saudi
public and private hospitals. The CBAHI sets quality and patient safety standards for all health
care establishments. To analyze healthcare personnel’s comprehension of medication mistakes,
reporting protocols, and predictors of reporting medication errors throughout Saudi Arabian
hospitals.
Common Medical Errors
Medication errors are a big issue in hospitals worldwide. MEs arise in hospitals for
several reasons. Pharmaceutical formulary restrictions need patient substitutions. Hospital
medical mistakes arise for many reasons. A lack of communication can lead to medical mistakes,
such as misdiagnosis . They may arise between a doctor, nurse, public health worker or
patient.(Alshammari et al., 2022) The same occurs for medical errors caused by technology
flaws. Technical failures include implants and medical equipment. Insufficient staffing may also
result in poor staffing patterns, increasing the risk of medical mistakes. Information overload
may also lead to medical errors. Patients are shifted from one hospital or department to another
without sufficient information flow. Not knowing essential facts that might impact prescription
selections can cause complications.(Alshammari et al., 2021)
Every day, doctors mess up. However, this isn’t always the case. Medication mistakes can
be fatal. The most common medication errors are dosage errors; patients must take the dosages
their bodies require. Too much or too little might make you sick. Incorrect dose can occur both
while prescribing and hospitalizing.(Alqenae et al., 2020) Errors in prescriptions arise when
doctors give the wrong medication or fail to address allergies or drug interactions. Wrong Drug
is regularly prescribed or administered. This is a disastrous mistake that affects everyone in
medicine, from doctors to pharmacists. The drug’s method of entrance into your body.(Alqenae
et al., 2020)
Overdosing on prescription medication is another common mistake. The doctor,
pharmacist, or patient may make this mistake. Taking medication at the inappropriate time is
common among the elderly. Patients may be given the wrong medicine or be misled. This leads
to people taking someone else’s prescription, which can be dangerous.(Tariq et al., 2018) Every
day, doctors must deal with a great number of patients, yet everyone must be treated as an
individual, lest the wrong prescription be prescribed.
Risks Associated with Medical Errors
It’s critical to comprehend medical blunders and their causes. The main reason is because
medical mistakes can injure both patients and caregivers, and in the worst instance, cause death.
Incorrect diagnosis might lead to unnecessary or harmful therapy (Tingle, 2017). A misdiagnosis
also means that the patient’s genuine disease would be handled slowly, if at all. Delay in
diagnosis can be as damaging as misdiagnosis. A delayed diagnosis may prevent timely therapy.
The patient’s health may also be threatened if the doctor prescribes the wrong dose or ignores
medication interactions. Doctors and caregivers should extensively evaluate a patient’s clinical
history for allergies and possible medication interactions.(Alharbi et al., 2019)
Adverse Drug Events (ADE) risk factors vary by patient, medication, and provider.
Polypharmacy, or taking more drugs than required, is perhaps the biggest risk factor. Elderly
individuals take more prescriptions and are more susceptible to certain pharmaceutical side
effects than younger patients.(Alsulami et al., 2019) Pediatric patients are particularly
vulnerable, as many drugs for children must be dosed according to weight. Lack of health
literacy and numeracy are also well-documented patient risk factors (the ability to use arithmetic
operations for daily tasks). Patient-level risk factors are probably an under-recognized cause of
ADEs in ambulatory care. Studies reveal that both caregivers (even parents of ill children) and
patients make medication mistakes often.(Alsulami et al., 2019)
The Institute for Safe Medication Practices keeps track of high-risk drugs that might
cause serious patient damage if misused. Drugs with serious side effects are included, as are
medications with identical names and outward appearance but radically distinct pharmacological
qualities. The Beers criteria have typically been used to assess pharmaceutical safety.
Conversely, the STOPP criteria (Screening Tool of Older Person’s Inappropriate Prescriptions)
have been demonstrated to better predict ADEs than the Beers criterion.(Rasool et al., 2020)
Process for submitting a report
When a medication error is identified, the following measures should be followed by
medical professionals: A paper-based reporting form must be filled out and sent within 24 hours
to a pharmaceutical safety office. Then, an inquiry into the incident and its underlying cause
must be conducted. In the website of the Ministry of Health’s General Department of
Pharmaceutical Care, a drug safety officer has documented the inaccuracy.(Alharbi et al., 2019).
One of its main goals is to collect all the information necessary to identify and correct
medication errors, along with the gender and age of patients, prescribed medications (such as the
name, drug category, and route of administration), error details (e.g., date, description, and
contributing factors), and the job level of staff who report and cause them. The reporting of
errors is completely up to the individual members of the medical team. Medical professionals,
patients, and consumers might all be at risk for medication errors, which are defined as any
avoidable incident that could lead to improper drug use and/or injury to patients. Prescriptions
and orders, product labels and nomenclature, packaging and distribution, compounding and
administration are only a few examples of events that may be connected to professional practice
and healthcare items, processes and systems.(Alshammari et al., 2022)
Reporting form
Six Sigma in Minimizing Medical Errors
The hospital can use the six-sigma problem-solving approach to improve the reporting
process and reduce the likelihood of a medical mistake. Six Sigma is a quality improvement
method in healthcare that helps enhance patient care, reduce waste, and eliminate faults like
medical blunders (Trakulsunti & Antony, 2018). Even though Six Sigma is a difficult concept to
grasp, the advantages far outweigh the negatives. Six Sigma teaches healthcare executives how
to manage operations while cutting costs and increasing efficiency. This quality improvement
strategy helps reduce variability in healthcare operations and identify best practices. Six Sigma
also helps manage change and enhance healthcare operations.
Six Sigma can reduce medical mistakes to zero by applying it in the institution. Six
Sigma supports sustainable and quick healthcare delivery (Miglani, 2015). This quality
improvement technique minimizes mortality. It also ensures patient safety, prompt service, and
improved care organization. The Six Sigma approach also decreases work completion time for
diagnostic laboratories and other departments. It also speeds up compensation claim
reimbursement. Six Sigma is crucial in healthcare to provide patient access to information. It also
ensures that patients’ views are considered while making healthcare choices. Ignoring this vital
voice may reduce demand for medical services. This might cost you a lot of money. Six Sigma
technologies are used in hospitals to help improve quality and solve issues(Miglani, 2015). The
DMAIC method is a well-known systematic problem-solving strategy.
DMAIC is a Six Sigma process improvement approach. DMAIC can be used to reduce
medical mistakes in a hospital. First, establish the medical mistake and the reporting process’s
goals. Following the facility’s specialists’ assessment, their performance must be measured.
Patient outcomes and clinical excellence can quantify adjustments or improvements. The
measurement data should be clear and straightforward, reflecting the medical mistake stated.
Then complex techniques are used to analyze the medical mistake. During the Improve stage, the
patient safety plan may need to be tweaked. To measure progress, this step involves a complete
evaluation of the improvements. The control step builds on previous progress. It may require
new policies, procedures, and other methods to ensure care meets DMAIC standards.(Trakulsunti
& Antony, 2018)
Departments Responsible for Following up on Errors
Various departments within a healthcare institution should be involved in tracking
medical mistakes, and each department should have a specific role. The hospital administration,
in particular, should play a crucial role in ensuring that every responsible department is carrying
out its responsibilities on time. The medical department, which is mostly comprised of
physicians, should be the first department to participate in the following-up process. Because
physicians are the ones who order and dispense pharmaceuticals, their department should be
involved in the investigation and follow-up of any medical mistakes that occur (Royce et al.,
2019). Additionally, the pharmacy department, which plays a critical role in the production and
dispensing of medicine, should be included in the follow-up of medication since they have a role
to play if a medical error arises. In addition, Additionally, the nursing department is the other
accountable unit that should be involved in the investigation of mistakes and their resolution.
Due to the fact that nurse practitioners are engaged in both the delivery and monitoring of
medicine, their participation in the follow-up process is essential. The pathology department that
is accountable for the medical error might also be included in the investigation and follow-up.
Because the pathology department is relatively vast, it is necessary to include a specific unit that
is associated with a certain medical mistake in the follow-up procedure.(Alsulami et al., 2019)
Conclusion
Patients’ experiences should be improved while the chance of damage is reduced,
according to practitioners. Despite the best efforts of healthcare professionals, the rate of medical
errors continues to remain high, resulting in significant disability and even death. Medical
mistakes, regardless of how they’re classified, are almost always the consequence of a series of
unfortunate circumstances (Alqenae et al., 2020). Medical mistakes that might have been
prevented have a major influence on healthcare spending, particularly in terms of higher perperson health coverage costs. Only by collaboration between healthcare professionals can the
cost and damage associated with medical mistakes be decreased. As a result, reporting medical
errors in our health-care institutions is an important step in the prevention of medical errors.
Identifying and reporting errors helps to reduce the risks associated with medical errors, which
are always harmful. For practitioners, failure to disclose mistakes may result in administrative
implications as well as an increased risk of legal consequences as a result of the failure to report.
Refrences
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