NRSG 314 Unit 2 – Discussion Board CTU
Medication errors are the most common type of medical errors. As per article “Reducing Medication Errors Using LSS Methodology: A Systematic Literature Review and Key Findings”, medication error is one the primary leading causes to the patient morbidity and mortality. Medication error can occur at every stage- medication delivery, prescribing, transcribing, dispensing and administration. The article states medication error can be preventable and that it is in the control of the healthcare professionals and patients (Trakulsunti, et al., 2020). In their book Quality and Safety in Nursing, Sherwood and Barnsteiner write that according to the World Health Organization, the rate of medication errors is estimated to occur in 10-20% of medication errors and that nurses can take the responsibility for improving the patient’s safety (Sherwood & Barnsteiner, 2021).
My recent nursing experiences include working as a home health nurse and as an urgent care nursing in an ambulatory setting. In home health care, medication errors usually occur at the administration stage. After being discharged home from the hospital, patients do not always understand the changes made to their medication regimen. For example, changes were made to their diuretic medication or new parameters were prescribed for their diuretic. The patients, for instance, do not understand to take an extra tablet of Lasix if there is a weight gain of 2 pounds or more or if there is an increase in edema. I have experienced that elderly patient, especially the ones without family support or without a caregiver, have issues with remembering instructions given to them on their discharge day from the hospital. Therefore, in our home health care, we have made every attempt possible to visit recently discharged patients within 24 to 48 hours to assess the patients and review the medication regimen. In addition, we always provide the patients a new list of their medications and compare each medication on the list with the actual mediation bottles in their home.
To reduce medication errors, in our urgent care, after confirming patient’s identity, we scan the medication prior to administering it. This is to ensure that we are giving the right medication with the correct strength and dose to the right patient. The computer would flag us if we scanned the wrong medication, wrong strength, or dose. However, this step is to prevent medication error when medication is administered by the nurses. Medication errors can still be made by the patients after leaving the urgent care. What I think could be done in addition to this workflow to prevent medication errors is to provide patients a list of their medication regimen and providers or nurses to thoroughly review any new medications or any changes made to medications reflecting the care provided at urgent care. Spending some time with the patients to review medications, to assess for their understanding and knowledge and to correct any discrepancies is one way to reduce any potential medication errors. Although I feel this is the best practice that should be done at every visit with every patient as it allows the patients in the decision-making process of their care, involves the patients to take responsibility and allows the patients ask questions or address any concerns, it is not always ideal as it is very time-consuming, and we don’t always have the staff or the resources to do so.
References
Trakulsunti, Y., Antony, J., Ghadge, A., and Gupta, S. (2020). Reducing medication errors using LSS methodology: a systematic literature review and key findings. Total Quality Management, 31(5-6), 550-568. https://doi.org/10.1080/14783363.2018.1434771
Sherwood, G., & Barnsteiner, J. (2021). Quality and Safety in Nursing (3rd Edition). Wiley Global Research (STMS). https://coloradotech.vitalsource.com/books/9781119684459
Primary Discussion Response is due by Thursday (11:59:59pm Central), Peer Responses are due by Saturday (11:59:59pm Central).
Primary Task Response: Within the Discussion Board area, write 250 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. You are required to use 1 scholarly resource, in addition to your textbook. Be substantive and clear, and use examples to reinforce your ideas.
In your current medical facility, or in any medical facility where you have recently worked, consider the following:
- Explain and describe what is being done or has been done to reduce medication errors.
- Analyze what could be done in addition to the current protocol to decrease medication errors.
Responses to Other Students: Respond to at least 2 of your fellow classmates with at least a 100-word reply about their Primary Task Response regarding items you found to be compelling and enlightening. To help you with your discussion, please consider the following questions:
- What did you learn from your classmate’s posting?
- What additional questions do you have after reading the posting?
- What clarification do you need regarding the posting?
- What differences or similarities do you see between your posting and other classmates’ postings?
Discussion Board Rubric
The Discussion Board Grading Rubric is a scoring tool that represents the performance expectations for the discussion. This grading rubric is divided into components that provide a clear description of what should be included within each component of the discussion. It is the road map that can help lead your discussion. Discussion Board Grading Rubric
For assistance with your assignment, please use your text, Web resources, and all course materials.
Several years ago, to reduce medication errors, Kaiser Permanente implemented One of my favorite technological safety tools called the Barcode Medication Administration system (B.C.M.A). This system works by scanning a barcode located on a patient’s wristband against the patient’s medication orders found in Health Connect and then the actual medication. This system has made it easy for nurses to carry out medication orders in a timely manner while improving patient safety and quality of care. According to data presented in Kathie Lynas article “Barcoding provides an automated double-check that significantly reduces medication errors, with many studies showing reductions of 70% to 80 %.” (Linas, 2010). B.C.M.A allows nurses to carry out their five medication rights in a safe and timely manner. The only time this system falls short is when nurses try to skip though and not use it. Some nurses feel that having to log onto the computer, scan the wristband and then scan the medication may take up too much of their time and will often seek to take a short cuts and skip using the B.C.M.A. However, there is no short cut when it comes to safety. I often encourage nurses to not rush and take those extra 1to 2 minutes to always play it safe. At the end of the day it is our license that is on the line.
Reference:
Lynas, K. (2010). A step forward for medication safety: Stakeholders agree to a common standard for barcoding pharmaceuticals: CPJRPC. Canadian Pharmacists Journal, 143(2), 62. https://coloradotech.idm.oclc.org/login?url=https://www.proquest.com/scholarly-journals/step-forward-medication-safety-stakeholders-agree/docview/89216105/se-2
In my current workplace, we have a “drug-diversion monitor” program in place called BlueSight, implemented so management can more efficiently audit medication orders from appropriate staff. This program tracks medications (using QR and bar codes), and the staff who order them, from the order all the way to the patient’s EHR; BlueSight also tracks the location in the facility, and the time that the medication was ordered/pulled. BlueSight, implemented 2 months ago, was in beta testing many months for quality assurance purposes; the purpose was to control a marked increase in narcotics diversion as well as medication errors. From this implementation, diversion has decreased and there is much greater accountability for med orders/pulls/disposals. Managers can now keep a closer eye on medications, and also have a centralized, collated structure for auditing such things.
Currently, BlueSight is only active for narcotic medications, which is a massive help for reducing the national opioid crisis. However, the obvious next step in reducing errors overall in my facility is to expand implementation of BlueSight to all medications ordered/pulled. The system is fully back-end operational, meaning that there is no change in the medication dispensing process for floor staff. Also, the system uses machine-learning to enhance its own algorithm for identifying medication errors and charting errors in the EHR, so the more information it is given, the more efficient it becomes at monitoring medication in our facility. In conclusion, a full rollout of BlueSight would be a significant step in making the patient care experience that much more efficient, streamlined, and understanding.
Several years ago, to reduce medication errors, Kaiser Permanente implemented One of my favorite technological safety tools called the Barcode Medication Administration system (B.C.M.A). This system works by scanning a barcode located on a patient’s wristband against the patient’s medication orders found in Health Connect and then the actual medication. This system has made it easy for nurses to carry out medication orders in a timely manner while improving patient safety and quality of care. According to data presented in Kathie Lynas article “Barcoding provides an automated double-check that significantly reduces medication errors, with many studies showing reductions of 70% to 80 %.” (Linas, 2010). B.C.M.A allows nurses to carry out their five medication rights in a safe and timely manner. The only time this system falls short is when nurses try to skip though and not use it. Some nurses feel that having to log onto the computer, scan the wristband and then scan the medication may take up too much of their time and will often seek to take a short cuts and skip using the B.C.M.A. However, there is no short cut when it comes to safety. I often encourage nurses to not rush and take those extra 1to 2 minutes to always play it safe. At the end of the day it is our license that is on the line.
Reference: