Addressing Patient Safety Risks Discussion Paper

Introduction

For successful recovery and to avoid any more or future illnesses, patients must be handled with care and provided with safe environments. Nurses form the majority of healthcare professionals, and they thus need to be at the forefront to ensure patients have access to safe healthcare environments. This paper focuses on enhancing the quality of the healthcare environment by addressing the issue of medication errors, their impacts on patients, and how they can be curtailed. Specifically, the paper will use a hypothetical situation that will be analyzed to develop solutions and show how nurses can be involved in achieving quality healthcare for patients.

Scenario

A hospital admits a patient with type 2 diabetes. The patient’s medication orders are keyed into the Electronic Health Record at the hospital, but due to a communication breakdown between the healthcare team, the patient is accidentally given a double dose of insulin. The excessive insulin dose leads to hypoglycemia; thus, the patient needs further medical intervention to repair the error.

Factors Leading to a Medication Administration Safety Risk for Patients with Diabetes

Patients with diabetes are always at risk of medication errors. The risk is heightened during hospitalization. Addressing Patient Safety Risks Discussion Paper Further, the management of diabetes is complex, and such patients often require constant medical supervision and medication (Adu et al., 2019). The medication’s dosing must be well titrated to suit personal needs and reflect on their conditions. For example, insulin dosing for diabetes patients must be well measured based on various factors, including blood glucose levels, carbohydrate intake, and physical activity. Any miscalculation or a communication breakdown between the nurses and other healthcare professionals taking care of the patient might lead to medical errors, a safety risk for a diabetes patient (Adu et al., 2019). In the scenario above, miscommunication between the healthcare team was the cause of the medication error of double insulin administration.

Solutions to Improving Medication Administration Safety and Reduce Costs

Standardized Order Sets for Diabetes Management

Standardized Order Sets (SOSs) are among the tools clinicians use to prescribe appropriate patient treatments. SOSs use a pre-defined set of applicable drugs and recommended dosages based on evidence-based guidelines for a specific disease area (Wells & Loshak, 2019). In the case of diabetes patients, nurses can employ SOSs to help ensure that medication orders are complete and accurate, reducing the risk of errors (Wells & Loshak, 2019). Further, the SOSs can help reduce costs by promoting cost-effective medications and reducing unnecessary testing.

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Barcode Medication Administration (BCMA) Technology

BCMA invokes using technology to eradicate human errors while managing a patient. BCMA, in particular, uses barcode scanning to verify patient identity and medication orders before administration. As such, professionals will ensure they always work within the prescribed medications and dosages (Mulac et al., 2021). In the scenario above, BCMA would have been beneficial as patient data would have shown they have already taken the medication, and any more would lead to double dosage (Mulac et al., 2021). Further, BCMA helps reduce costs as it eliminates the need for paper medication and leads to lower wastage of medication.

Implementing Effective Interdisciplinary Communication

Clear and concise communication between healthcare providers reduces the risk of errors. One way that nurses can communicate well is by implementing the Situation, Background, Assessment, Recommendation (SBAR) Communication Tool (Müller et al., 2018). That way, the professionals will always know about the patient and provide the correct dosage and medication (Müller et al., 2018). Further, effective communication can help reduce costs by promoting efficient care coordination and reducing unnecessary testing.

How Nurses Can Help Coordinate Care to Increase Patient Safety and Reduce Costs

Nurses are essential in coordinating care and promoting patient safety. One way nurses can prove essential in such cases is by utilizing their knowledge of evidence-based practices to ensure that medication orders are complete and accurate. The nurses can also use relevant technology such as Barcode Medication Administration (BCMA) which limits human errors while administering medication to patients. Finally, nurses have to be good communicators. Nurses will be instrumental in coordinating care and improving patient healthcare quality through proper communication channels among the healthcare provider team.

Stakeholders Involved in Driving Safety Enhancements with Medication Administration

Nurses could coordinate with several stakeholders to drive safety enhancements with medication administration. According to (the Department of Health & Human Services, 2020), these stakeholders include, among others:

• Physicians: are responsible for prescribing medications and ensuring that medication orders are accurate and appropriate for patients.
• Pharmacists: ensure that medications are dispensed accurately and provide valuable guidance on medication management.
• Healthcare administrators ensure that resources are allocated effectively to support safe and efficient medication administration.

References

Adu, M. D., Malabu, U. H., Malau-Aduli, A. E. O., & Malau-Aduli, B. S. (2019). Enablers and barriers to effective diabetes self-management: A multi-national investigation. PLOS ONE, 14(6), e0217771. https://doi.org/10.1371/journal.pone.0217771

Department of Health & Human Services. (2020). Hospital staff roles. Better Health Channel. https://www.betterhealth.vic.gov.au/health/servicesandsupport/hospital-staff-roles#bhc-content

Mulac, A., Mathiesen, L., Taxis, K., & Granås, A. G. (2021). Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open, 8(8), e022202. https://doi.org/10.1136/bmjopen-2018-022202

Wells, C., & Loshak, H. (2019). Standardized Hospital Order Sets in Acute Care: A Review of Clinical Evidence, Cost-Effectiveness, and Guidelines. CADTH Rapid Response Report. https://www.ncbi.nlm.nih.gov/books/NBK546326/

Addressing Patient Safety Risks Discussion Paper