Patient safety is an important part of nursing and is an expectation by the patient. According to the Institute of Medicine report, between 44,000 and 98,000 people die in hospitals each year from preventable medical errors (Kohn, Corrigan, & Donaldson, 1999). Medical error is defined by the IOM as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (Kohn et. al., 1999). Some examples of these errors that commonly happen are adverse drug events, falls, wrong-site surgeries, pressure ulcers, and even death. Nurses are closely involved in the delivery of health care and are responsible for the patient care in their acute phases of disease. Errors detected by nurses include those involving medication, procedures, charting, and transcription (Rogers, Dean, Hwang, & Scott, 2008). “Research has shown that these errors often result from a combination of factors that lead to the breakdown of work flow” (Hakimzada, Green, Sayan, Zhang, & Patel, 2008). For this paper, I will be discussing medication error.
Of particular concern to nursing practice is the fact that medication errors are second only to errors in prescribing medications (Bates, Cullen, Laird, Small, & Servi, 1995). Medication administration is a basic nursing responsibility, as is providing safe administration practice. The practice of using information technology to promote safe medication practice allows for reducing or preventing medication administration errors.
The reporting of medical errors and near misses has been shown to improve patient safety. A non-punitive culture needs to be considered a priority in eliminating medical errors. Health care systems find achieving a non-punitive culture and improving error reporting difficult to accomplish. System problems can be detected through these types of reports, which can occur 300 times more frequently than adverse events, and provide valuable information for proactively reducing errors and increasing patient safety (Wolf & Hughes, 2008).
Statement of the Problem
The research of Kohn, Corrigan & Donaldson was the basis of the IOM report on the scope and impact of medical errors (2000). Two studies were cited by the IOM, which used similar methodologies; one was presented in a 1991New York study from data collected from 1984 and the other was presented in 2000 from data that was collected in Colorado and Utah from 1992 (Leape, Brennan, Laird, Lawthers, Localio & Barnes, 1991; Thomas, Studdert, Burstin, Orav, Zeena, & Williams, 2000). Extensively referenced was the number of deaths (48,000 from the Colorado/Utah study to 98,000 from the New York research) associated with medical errors. The New York researchers identified the types of medical errors that resulted in adverse events (AE) (Leape et. al., 1991). They discovered that adverse events that were medication related were the second highest incidence of all adverse events. They concluded that of all the preventable AEs, only a small amount (10%) was believed to preventable (1991). The study reasoned that while a large proportion of AEs were not preventable, the increasing frequency of drug-related AEs warranted the development of strategies to prevent medication errors that would prevent AEs.
Medication error research has always centered on the process of medication administration (Bates et.al., 1995). The medication administration process has been defined as having four steps: ordering, transcribing, dispensing, and administering. The investigators, Bates and colleagues, revealed that medication errors happened more frequently in the steps of ordering and administration (1995). The researchers also estimated that prevention of medication errors at the level of ordering and administration could significantly reduce adverse events. The findings of various studies, although limited due to methodological discrepancies point to a need to reduce medication errors (Bates et. al., 1995; Leape et. al., 1991, & Barker, Flynn, Pepper, Bates, Mikeal, 2002).
Nursing Medication Administration
According to a study of nursing interventions, nurses administer medications many times in their shift (Bulechek, McCloskey, Titler, & Denehey, 1994). Medication administration as a nursing intervention is second only to being an active listener. Therefore, with medication administrations being a fundamental component of nursing, medication errors have been classified as a befitting outcome indicator for nursing practice (American Nurses Association, 1995).
Nurses are taught to obey the five rights, “The nurse gives the (1) right medicine to the (2) right patient in the (3) right dosage through the (4) right route at the (5) right time” (Taylor, Lillis, & Lemone, 2001, pg. 581). During the preparation to administer medications, the nurse is in charge of confirming the order, the time of administration, and choosing the appropriate medication and dose. At the bedside, it is the nurse’s accountability to identify the correct patient and route of administration. Historically, the standard of care has been to check the patients identification bracelet and verbally confirm two patient identifiers (patient’s name and date of birth) with the patient. Over the last decade, information technology has interposed methods to reduce the most commonly occurring and preventable medication errors.
Avedis Donabedian’s model presents an all-inclusive model of the relationship between variables that contribute to quality of care, healthcare costs and health status. Donabedian’s (1988) classical approach to the assessment of the quality of patient care within a hospitalization setting is comprised of three components, which include: structure, process, and outcome. The first two variables, structure and process, are labeled indirect variables, because of their overall significance and contribution to the third variable, outcome (Postema, 2005).
The structural component is defined by the setting, which includes the “attributes of material resources (such as facilities, equipment, and money), of human resources (such as the number and qualifications of personnel), and of organizational structure (such as medical staff organization, methods of peer review, and methods of reimbursement)” (Donabedian, pg. 1745). Examples of the structural component include the physical working environment, staffing mix and ratios of patients to nurse, and the organizational culture itself (institutional policies). The structural component of the model emphasizes characteristics of nurses involved in each patient’s care; certain characteristics of the patient, as well as the organizational structure of the hospital in which the patient care was received (Duffy & Hoskins, 2002). The second variable of consideration in Donabedian’s model the process component, which he defines as “giving and receiving care” (pg. 1745) is the specific intervention or interventions, which includes patient and provider
participation. Finally, the third component of Donabedian’s model for assessing the quality of care is the outcome component of the model, which is defined as “the effects of care on the health status of patients and populations” (pg. 1745).
Donabedian’s model attempts to explain health care quality in terms of outcomes in terms that are measurable by the interrelationship between the structure, process and other attributable variables such as the improvement in a patients’ health status and satisfaction (1988). Donabedian’s model plays a significant role in the assessment of quality of care from the patient’s perception and is a high priority in the “pay for performance” reform within the past decade (Wachter, Foster, & Dudley, 2008), specifically from the Centers for Medicare and Medicaid Services (CMS).
Evidence supports Donabedian’s theory relative to the interrelationship between the process components, such as the care provided, and the outcome of the patient’s health leading (Duffy & Hoskins, 2003). Research posits that the three-part approach to the assessment of a patient’s quality of care is legitimately rooted in the relationship among the variables set forth by Donabedian: structure, process, and outcome (Duffy & Hoskins, 2002). Donabedian proposed, “good structure increases the chances of good process, and good process increases the chances of good outcomes” (Donabedian, 1988, pg. 1745). Additional researchers in their research (Duffy & Hoskins, 2002 and Postema, 2005), substantiated Donabedian’s framework through a variety of methodological approaches, yet were able to find the overarching correlations between factors of structure and factors of structure to produce positive outcome measures among patients upon their discharge. Thus, it can be concluded that utilization of Donabedian’s approach to the assessment of quality of care among hospitalized patients can assist in producing higher quality outcome measures, such as the problem facing many institutions relative to the number of medication errors.
Donabedian’s model of structure, process, and outcome will be used to facilitate my endeavors in decreasing medication errors on the Psych-Med Unit (PMU) at St. Mary’s Health Care System. A detailed discussion of the appropriate variables will follow to provide a more thorough understanding of how the application of this theory will assist in the decreasing the number of medication errors
The structure component of the model includes nurse characteristics, patient characteristics, and factors related to the organization.
There is overwhelming evidence that the combination of higher education and years of experience in nursing improves health care outcomes, such as decreased medication errors, lower fall rates, and reducing mortality rates (Tourangeau et. al., 2006; Blegen, Vaughn & Goode, 2001), and are related to better patient outcomes (Aiken, Clarke, Sloane, & Silber, 2003; Tourangeau, Cranley & Jeffs, 2006). Tourangeau et. al.’s research (2006) found that more years in nursing experience has a significant and beneficial effect on patient health specifically on 30-day mortality rates in hospitals. Aiken et. al. (2003) found a statistically significant effect which postulates that with an increase in baccalaureate nurses in staffing – which is associated with an increased awareness of the culture of safety, there was a decrease in mortality of patients within 30 days of admission. In another study, which specifically examined nursing characteristics related to medication error, rates, nursing units with experienced nurses had lower medication error rates (Blegen, Vaughn & Goode, 2001).
Patient characteristics, such as polypharmacy and multiple diagnoses have been shown to impact medication safety. Comorbid diagnosis are associated with the need for the patient to take more medication to manage symptoms and in turn, increases the risk of drug interactions, potential side effects and thus, the need for more medications, errors in the administration of medication, as well as difficulties with compliance upon discharge from the hospital (World Health Organization, 2011). According to the Joint Commission on Accreditation of Healthcare Organizations (JACHO, 2008), polypharmacy can cause an increased risk for falls, hospitalizations and confusion (pg. 8). Dr. Joseph Parks, a director for comprehensive psychiatric services for the Missouri Department of Mental Health, commented that, “polypharmacy issues within psychiatry occur because one provider does not know what the other provider is prescribing” and is a significant factor that diminishes the overall patient’s quality of care based on potential side effects and adverse interactions (JACHO, 2008, pg. 9). Literature has identified that with multiple physicians prescribing medications for one patient, there is increase in chance for medication errors and thereby, diminishing the patient’s overall quality of care. (Tamblyn, McLeod, Abrahamowicz & Laprise, 1996). This issue is reliant upon patient report, as well as doctor inquiry and thus, the burden falls upon both parties in order to ensure high quality of care.
Having a culture that encourages and elevates safety efforts has been recognized in healthcare organizations as an essential component in improving patient safety (Singer, Gaba, Geppert, Sinaiko, Howard & Park, 2003). Healthcare organizations have appropriated safety culture theories from trades such as aviation and nuclear energy by applying communication and teamwork models, and producing working situations that encourage patient safety. The main factors of a culture of safety include an obligation to safety at the uppermost levels of management and mutual values and beliefs, and that there is honesty in reporting errors and problems. The reaction to an error emphasizes refining system performance rather than on singular blame and is non-punitive (McCarthy & Blumenthal, 2006).
The Robert Wood Johnson Foundation (2008), whose mission is to improve health and healthcare for Americans, found that hospitals and health systems across the country have been working to achieve the culture of safety in their organizations to develop supportive work environments that encourage nursing retention and improved quality of patient care. With a keen awareness of culture of safety often attributed to nursing professionals with higher educational degrees, there is an enhanced awareness that the safety of patients is the utmost priority and is highly valued on an organizational level. Because of the value placed on the culture of safety by health organizations and hospitals each year, staff and other health professionals need to continue to focus on improving their precision and skill utilized while caring for patients. In doing this, they become not only aware of potential medication errors, but also avenues to implement interventions to eliminate the tendency of potential risk all together (Institute of Safe Medication Practice, 2006).
The organizational structure characteristics including staffing ratios, staffing mixes, hospital’s policy in medication administration and the organizational culture itself can influence the outcomes of care (Duffy & Hoskins, 2003). Environmental factors that can encourage medication errors include “inadequate lighting, cluttered work environments, increased patient acuity, distractions during drug preparation or administration, and nurse fatigue” (Anderson & Townsend, 2010, pg. 2). Distractions and interruptions can disturb the nurse’s focus, which can result in grave errors. Substantial patient assignments are also connected to medication errors. The nursing shortage has amplified workloads by the rising number of patients for which a nurse is accountable (Anderson & Townsend, 2010).
Throughout the years numerous studies have been conducted that show that a “higher registered nurse mix was related to lower mortality” because that demonstrates the professionalism and integrity of registered nurses (Tourangeau et. al, 2006, pg.5). An increase in nursing staffing providing care has been shown to result in decreased mortality (Tourangeau et. al., 2006), which supports the necessity of higher ratio of registered nurses mix in staffing patterns.
Bar code scanning
As stated previously, process components “the giving and receiving of care” (Donabedian, 1988). A solution that has shown to improve medication administration and thus decrease medication errors is through the use of barcode scanning systems for dosing and medication administration (ISMP, 2002). The ISMP (2002) asserts their confidence in the barcode scanning system by encouraging the use of the technology in any setting which medication is administered. The Institute of Medicine released a report in 2001 that suggested ways to use information technology to come through with a safer, more efficient way to prevent medication errors and improve healthcare quality with the automation of patient-specific clinical information (pg. 5). Medication administration errors are responsible for one-third of the errors (ISMP, 2002). According to the ISMP a bar coding and scanning system is a promising attempt at the reduction of errors in the stage of medication administration based on the accountability and accuracy of this technology (2002). At a patient’s bedside, bar code scanning identifies the patient, lists the medications ordered, checks for allergies or alerts for medication interactions, and electronically signs the patient record for the nurse (ISMP, 2002).
Donabedian’s Assessment of Patient Quality Care: St. Mary’s Health Care System
St. Mary’s in Grand Rapids already has this bar code scanning system. The issue on the PMU is the work arounds nursing professionals have implemented to make their medication administration “easier”. These “work arounds” are ways nurses can still administer medications without scanning the medication and/or patient’s identification band; despite the benefits it provides to the staff, it raises a variety of risks for the patients and puts them in great danger for adverse medication reactions, multiple dosing, incorrect dosing, and other problems. There are other issues reported by nurses that make the “work arounds” essential, such as the all-too-common issues faced with the use of technology. These include technological malfunctions, limited availability despite the demand for the equipment, and sometimes merely, the time it consumes to find the equipment making the use of such technology more “time consuming”.
As a registered nurse for over nearly 30 years, the bar code system is proven advantageous and significant in the quality of patient care based on the mere assumption that under hospital care, the utmost elite care is to be provided – including medication administration. The bar code and scanning procedural implementation enables nurses to look at the order (medication/dosage), when it was last administered, the dosing, as well as if there are any potential medication interactions to be on the alert for, medication allergies, and whether there are any safety or physical maladies due to missed doses or inaccurate administration (ISMP, 2002). Finally, the technological advances provided for nursing professionals are implemented in order to better account for patient care and safety. The bar code and scanning system is computer-oriented and therefore, supplies a database and record for future use in the event there is any debate about the procedure utilized while hospitalized or even during hospitalization at an alternate hospital.
Literature has identified that there is an alliance between professional nursing care and positive health outcomes (Duffy & Hoskins, 2003). Identifying ways to improve the process of medication administration can improve medication errors. Bar code scanning technology offers a productive way to avoid medications errors and increase patient safety (Begliomini, 2012). Measuring medication errors can be accomplished using many different processes; but with computer analysis of the patient’s information, measurement becomes much easier, more capable, and feasible than error reporting or reviewing charts for purposes of “accountability, prevention, and ongoing improvement of both process and clinical practice” (Classen & Metzger, 2003, pg. 41). In summary, the literature reinforces the idea that a decrease in patient medication errors is best accomplished by use of the bar code scanning for medication administration and therefore a responsibility for the nurse.
As St. Mary’s in Grand Rapids already has instituted the barcode scanning for medication administration, the intervention that I am proposing for the PMU at St. Mary’s is to reinforce the medication administration policy with the use of barcode scanning and to share the importance of compliance with barcode scanning utilization on reducing medication errors. The continuing education of nursing staff in safe medication administration practices can assist in lowering medication errors and staff should be kept informed of medication errors.
There are numerous approaches on how to measure the effectiveness of the intervention I am proposing. One such avenue is the fact that this is an electronic database and therefore, can be accessed for medication errors and nursing adherence. With the institution of computerized analysis of patient information, measurement is much stress-free and possibly more influential and attainable than incident reporting of chart reviews for purposes of responsibility, hindrance, and continuing improvement of both process and clinical practice (Classen & Metzger, 2003). An interview/ survey with nursing could be another avenue for measurement on the adherence of the nurses with the use of barcode scanning. A key to successful application and use of barcode scanning for medication administration is to realize the level of approval the nurses have with the system and how the system can prevent medication errors.