How does the integration of electronic health records (EHRs) and health information systems enhance data availability

How can health care professionals navigate conflicts of interest and remain unbiased in their ethical decision-making process?

What are the personal and/or communal ethical factors that may be involved in determining the moral position of either side in that debate?

RCA is a tool designed to help identify not only what and how an event occurred, but also why it happened

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Running head: MEDICATION ERRORS IN THE HEATHCARE SETTING 1

MEDICATION ERRORS 9

Medication Errors in the Healthcare Setting

Student Name

X Community College

NURS 2448 Restorative 2

Melissa Wolff

Due Date

Abstract

This root cause analysis paper focuses on medications errors which occur in the healthcare setting from lack of communication and distractions. These factors are present in a statement where two nurses fail to use communication and are distracted by environmental influences, which overall lead to a medication error which could have caused a sentinel event to occur. Through data collection and analyzing the sequence of events which lead to the error, this paper will examine ways in which evidenced based practice can be implemented to prevent medication errors like this from occurring in the future.

Keywords: medication errors, communication, distractions

Medication errors cause at least one death every day, and injure approximately 1.3 million people annually in the United States (“Medication Error Report,” n.d.). A medication error can occur at any time during the medication administration process, from when the doctor writes the order to when the patient takes the medication. It is important for those who administer medications to be competent about the medication, while also following the seven rights of medication administration. There are many factors which can lead to medication errors, specifically lack of communication and distractions. Through utilizing evidence based practice, one will be able to learn ways to prevent medication errors from occurring.

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One day while at work I witnessed a medication error occur between two nurses. Sally, one of the residents, suffers from major anxiety which impairs her ability to function normally. As part of Sally’s morning medications, she receives an Ativan along with her other medications. On this particular day, the primary nurse was in charge of passing medications and was also training, which lengthened her medication pass. It takes longer to explain how things are done when training in a new employee. When the primary nurse went to give Sally her pills, Sally refused her medications. Normal protocol when a resident on the memory care unit refuses their medications is to have another staff member attempt giving the medication before documenting a refusal. After Sally refused the medication, the primary nurse called the nurse supervisor to attempt giving Sally her pills. In preventing Sally feeling overwhelmed when taking her pills, the nurse supervisor took just the Ativan out of the medication cup, and left the remaining pills on the medication cart with the primary nurse. The primary nurse placed Sally’s medication to the side on top of the cart, so she was able to get other patients pills started in attempt to stay on track. As the nurse supervisors attempt also failed at giving Sally her Ativan, the nurse supervisor then returned the Ativan to the medication cart to put it back with her other pills. The nurse supervisor dumped the Ativan in another patient’s cup not realizing they were not Sally’s pills, and left in a hurry returning to her work. The primary nurse did not realize this at the time, because one of the Certified Nursing Assistants (CNAs) was talking to them about another issue. After her conversation, the primary nurse went to deliver other patients pills. When they returned, they were again going to attempt to give the Ativan to Sally. When the primary nurse went to take the Ativan out of Sally’s medication cup, the primary nurse realized it was not in her cup and the Ativan must have been dumped into the other patient’s cup, which she just gave. When a medication error occurs, a rapid letter must be sent to the patient doctor explaining what happened, along with starting a 24 hour vital sheet, and corrective action taken for the staff who were involved in the error. All of this could have been prevented with better communication and lack of distraction.

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After reviewing the problem statement, we will now collect data based on the situation to determine the contributing factors which lead to the event. One of the reasons the medication error occurred was due to the primary nurse training in a new employee and already being behind in their medication pass. On top of training, the primary nurse was also on a memory care unit, which can often times be nosey and one can easily become distracted. According to Choo, Hutchinson & Bucknall (2010), environmental conditions such as poor lighting, interruptions and poor communication within teams lead to medication errors. Distractions play a huge role in a person’s work environment and involve events which hinder the medication administration process through sidetracking the nurse’s attention. With the nurse having to talk to the CNA, this was another factor which led to the event. A study by Mayo and Duncan found nurses who were distracted by other patients, co-workers or events happening on the unit reported they made medication errors (Choo et al., 2010). When the house supervisor came to return the Ativan, she was in a hurry to get back to her work, which is why she assumed she had the correct medication cup and proceeded to dump the Ativan in it. According to Judd (2013), failure in communication is the main cause of sentinel events, medication errors, and preventable costs which result in inadequate treatment for patients. Keeping in mind these outcomes from poor communication, it is important to analyze the events which lead to medication errors and determine ways in which they can be prevented.

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After collecting data, we will look at ways in which the communication between the nurses could have been improved and ultimately prevented the medication error for happening. The nurse supervisor could have waited until the primary nurse was done with their conversation with the CNA. This way, the nurse supervisor could ask which medication cup was Sally’s, which would ensure the Ativan was being placed in the correct medication cup. In this case, the nurse supervisor assumed she had the right medication cup and ended up putting the Ativan in another patient’s cup. The nurse supervisor was also in a hurry to get back to her work, which also lead to the medication error occurring. Communication could have been improved through having the primary nurse stopping the conversation with the CNA to make sure the Ativan was put back in Sally’s cup. If active listening was implemented in this situation, the medication error could have been prevented. Nonverbal communication could have been implemented by the nurse supervisor labeling a separate cup with the residents initials and room number (since rooms numbers do not change in this facility), and then the primary nurse could have put the Ativan in the correct cup once they were done discussing a situation with the CNA. In this case, too many people were in charge of the medications which lead to a breech in communication and ultimately resulting in the medication error. Possessing good interpersonal communication skills leads to professional relationships which provide growth in the nursing profession and allow employees to work well together.

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After analyzing the sequence of events which lead to the error, we will look at ways to implement evidenced based practice so future errors can be prevented. In a study done by Flynn, Evanish, Fernald, Hutchinson, and Lefaiver (2016), they implemented the Nurses Uninterrupted Passing Medications Safely (NUPASS) guidelines for nurses to follow while passing medications to decrease the amount of medication errors from occurring. For nurses to not be interrupted during their medication pass, they should don a yellow safety vest before leaving the medication room (Flynn et al., 2016). Not only did they design a vest to wear to alert others the nurse was passing medications, and should not be interrupted, but they also designated a room for those who are passing medications to have a “quiet zone”. Designating a proper administration room for medications would also be beneficial to reduce the interruptions which occurred in the problem statement. This would significantly decrease distractions by allowing the nurse to work in a quite environment and allow them to concentrate and have their attention on dispensing their medications. According to Flynn et al. (2016), implementing a No Interruption Zone (NIZ), would be beneficial by outlining an area on the floor. When a nurse is within the NIZ, no one is to interrupt the nurse. By doing this, one study showed avoidable interruptions decreases from 18 to 3 (83%) on one unit and from 19 to 9 (53%) on another unit after applying the NUPASS guidelines (Flynn et al., 2016). This study greatly supported the use of evidenced based practice to eliminate disruptions pertaining to medication errors.

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After reviewing evidenced based practice for disruptions, we will now use evidenced based practice and look at ways it can improve communication among coworkers. Current research indicates that ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm (Dingley, Daugherty, Derieg, & Persing, 2008). Medication errors are often caused by lack of appropriate communication between staff members which in turn plays a contributing role in adverse events. In a study done by Dingley et al. (2008), they found “using daily briefings was useful in assessing change in clinical workload, and identifying relevant issues of the day, and provided a means to prioritize.” This study also developed a toolkit which can be purchased on the internet and be implemented in different healthcare settings. This toolkit provides information on ways to improve teamwork and communication in the healthcare setting. According to Dingley et al. (2008), they also encourage management and leaders to demonstrate teamwork and communication to show how important these factors are in contributing to patient safety and staff satisfaction. Overall, teamwork and communication are vital factors which contribute to the patient’s safety and wellbeing.

Nurses deal with a great amount of responsibly and challenges every day at work, along with having to deal with multiple demands. This results in nurses being in situations which put them at increased risk for making a medication error. “Medication errors are never the result of a single, isolated human error but comprise a chain of events leading to an error” (Choo et al., 2010). It is important safe practices are put in place to prevent these errors from occurring in the future. By initiating “quiet zones”, NIZ, and wearing vests to alter others you are passing medications, will ultimately result in fewer interruptions during a medication pass. Having staff properly educated on teamwork and collaboration will also positively impact the work environment and prevent errors from occurring. Overall, patient safety is the number one priority in any healthcare setting. Through implementing these practices this will greatly reduce the likely hood of a sentinel event from occurring in the future.

Casual Factor Chart

Sally is due for her morning medications

Steps leading up to event

Root Cause

Primary Nurse- Give Sally her medications

Sally refuses her medications

Sally takes her medications

Primary Nurse continues with med pass (sets up other patient’s pills)

Primary Nurse contacts House Supervisor to attempt

Successful

House Supervisor attempts to give medication

Not successful return to med cart

Take out Ativan

Sally’s pills are pushed to the side on top of med cart

Other patient’s pills are set up on top of med cart

Ativan was put in wrong resident medication cup

Attempt to give just the Ativan

Return Ativan to medication cup

Sally’s pills are set up on med cart

Not successful

If successful, will come back later to give rest of pills

References

Choo, J., Hutchinson, A., & Bucknall, T. (2010). Nurses' role in medication safety. Journal of Nursing Management, 18(7), 853-861. doi:10.1111/j.1365-2834.2010.01164.x

Dingley, C., Daugherty, K., Derieg, M., & Persing, R. (2008). Improving Patient Safety Through Provider Communication Strategy Enhancements. Retrieved November 9, 2016, from https://www.ncbi.nlm.nih.gov/books/NBK43663/?report=reader.

Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration. Critical Care Nurse, 36(4), 19-35. doi:10.4037/ccn2016498

Judd, M. (2013). Broken Communication in Nursing Can Kill: Teaching Communication Is Vital. Creative Nursing, 19(2), 101-104. doi:10.1891/1078-4535.19.2.10

Medication Error Reports. (n.d.). Retrieved October 30, 2016, from http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm

address an alternative or complementary therapy or theory of health

Develop care coordination strategy based on a health care concern

Four Spheres of Care Activity

Use  at least 100 words and no more than 400 words for each of the four required journal entries in this activity. You do not need to include scholarly resources or a reference list. Your reflections should be your own original thoughts. Please do not include patient or clinic identifying information.

When you are finished with all four, select Save Entries and then Output Activity. Submit the resulting PDF to your assessment.

Wellness and Disease Prevention:

Reflect on the health promotion disease prevention interventions you witnessed in your practicum site, as it relates to the social determinants of health most prevalent in your community. What did you see? What does this time mean to you as a professional nurse in your role?

Respond with at least 100 words.

0/100 min words

Chronic Disease Management:

Reflect on the integration of interprofessional team-based care as it relates to chronic disease management in your practicum site this week. What did you see? What does this time mean to you as a professional nurse in your role?

Respond with at least 100 words.

0/100 min words

Regenerative and Restorative Care:

Reflect on the acute management of illnesses such as stroke, mental illness, and falls in your practicum site this week. What did you see? What does this time mean to you as a professional nurse in your role?

Respond with at least 100 words.

0/100 min words

Hospice and Palliative Care:

Reflect on end-of-life nursing and advanced illness and hospice care in your practicum site this week. What did you see? What does this time mean to you as a professional nurse in your role?

Respond with at least 100 words.

0/100 min words

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For this assessment, you will develop the final care coordination strategy you based on your health care concern and population in Assessment 2 using best practices found in the literature.

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Introduction

This assessment builds on your initial care coordination infographic by providing an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for your selected health care problem.

Note: You are required to complete this assessment  only after Assessment 2 is successfully completed.

Professional Context

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

Please watch the following brief video message for an overview of what to keep in mind as you complete your Care Coordination Strategy.

· Final Care Coordination Strategy .

Preparation

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

In this assessment, you will evaluate the preliminary care coordination infographic you developed in Assessment 2 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the strategy based upon evidence-based practice and discuss how the strategy includes elements of  Healthy People 2030 .

Instructions

Build on your preliminary care infographic and selected health concern and population and create a detailed comprehensive final care coordination strategy.

It is suggested that you use the following outline to organize your 5–7 page paper, including headings:

· Design patient-centered health interventions and timelines for your selected healthcare problem. 

· Address three patient healthcare issues related to your selected healthcare problem and patient population

· Example: Healthcare problem: Type 1 diabetes in pediatric patients.

· Health issues.

· Depression.

· Exercise.

· Poor glucose control.

· Design an intervention for each health issue.

· Identify three community resources for each health intervention.

· Establish timelines for implementing these interventions.

· Include evidence to support your ideas.

· Consider the ethical decisions in designing patient-centered health interventions for your selected healthcare problem.

· Include the ethical questions that generate uncertainty about the decisions you have made.

· Include evidence to support your ideas.

· Identify relevant health policy implications for the coordination and continuum of care of your selected healthcare problem and population.

· Cite  specific health policy provisions.

· Include evidence to support your ideas.

· Describe the priorities a care coordinator would establish when discussing the plan with a patient and family members.

· Include evidence to support your ideas

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.

· Clearly explain the need for the changes to the plan.

The requirements, outlined above correspond to the grading criteria in the Final Care Coordination Strategy scoring guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Format and Length

· Write a 5–7 page APA-formatted scholarly paper (excluding title page and reference list).

· Include five evidence-based resources.

· Properly cite evidence throughout your paper.

Good luck with your care coordination plan!

Practicum Hours Submission

· Use  Capella Academic Portal  to submit your practicum hours.

· You must  complete any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.

· Failure to complete the required practicum hours will result in a  non-performance for this assessment.

Please review the  BSN Practicum  Campus page for more information and instructions on how to log your hours.

Nursing Reflection Journal: Four Spheres of Care

Reflective Journaling

Reflective journaling serves as a powerful tool for self-reflection during your academic journey. Reflective journaling enables you to assess your performance and to develop the regular practice of self-reflection. During your practicum, you’ll complete  four reflective journal entries, each aligned with one of the four spheres of care.

For your first entry, you can choose any of the four spheres, but you will need to complete all four by the end of the course. Remember that you’ll need to submit your completed nursing reflection as part of the final assessment for the course.

Instructions

Complete your first entry in 100–400 words in the  Nursing Reflection Journal: Four Spheres of Care  activity. You do not need to include scholarly resources or a reference list. Your reflections should be your own original thoughts. Please do not include patient or clinic identifying information.

As you complete your practicum hours (total of 40 hours required), it is good practice to complete a reflection journal entry every 10 hours. Take a moment to review the four spheres of care and the assigned readings for each assessment. This can help you focus your practicum time on specifics of learning and experiencing the courseroom content.

AACN Definition of the Four Spheres of Care

Wellness and disease prevention: This sphere emphasizes health promotion, as well as the treatment of minor uncomplicated diseases or injuries for those not experiencing chronic illness or life-limiting conditions. Prenatal care, screenings, immunizations, and health promotion are some examples of care in this sphere (AACN, 2021). Nursing knowledge and competency in disease prevention and addressing social determinants of health are vital to promoting wellness across populations.

Chronic disease management: This sphere encompasses caring for those with one or more chronic diseases and preventing adverse outcomes associated with them. Specialized nursing care is often needed for this population due to the complex needs, along with integrated interprofessional team-based care. Four in 10 Americans have two or more chronic diseases, and those diagnosed with multiple comorbidities are projected to increase.

Regenerative and restorative care: This sphere includes critical and trauma care, complex acute care, acute exacerbations of chronic disease, and care of unstable patients who are typically in acute care hospital settings (AACN, 2021). This sphere includes the acute management of illness, such as a stroke or mental health crisis, and progression through the rehabilitative phase. Nursing skills and management of these populations are resource-intensive and specialized.

Hospice and palliative care: The final sphere relates to competencies surrounding palliative care in advanced illness and hospice care at the end of life. All registered nurses provide generalist palliative care in compassionate and patient-centered care while managing pain and other symptoms associated with advanced, progressive illness. The End-of-Life Nursing Education Consortium has mapped its Competencies and Recommendations for Educating Nursing Students competencies to the new AACN Essentials to assist educators in this endeavor.

Reflection Questions

By the end of your practicum, make sure that you have answered each of these questions.

· Wellness and disease prevention: Reflect on the health promotion disease prevention interventions you witnessed in your practicum site, as it relates to the social determinants of health most prevalent in your community. What did you see? What does this time mean to you as a professional nurse in your role? 

· Chronic disease management: Reflect on the integration of interprofessional team-based care as it relates to chronic disease management in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?

· Regenerative and restorative care: Reflect on the acute management of illnesses such as stroke, mental illness, and falls in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?

· Hospice and palliative care: Reflect on end-of-life nursing and advanced illness and hospice care in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?

Reference

American Association of Colleges of Nursing. (2021).  The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Essentials/Essentials-Executive-Summary.pdf

Completion Checklist

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Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Create a patient centered strategy to achieve desired health outcomes.

· Design patient-centered health interventions and timelines for a selected healthcare problem.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family members.

· Competency 2: Apply the code of ethics for nursing to care coordination decisions.

· Consider the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, supporting ideas with the literature.

· Competency 3: Explain how health care policies affect the coordination of patient centered care.

· Identify relevant health policy implications for the coordination and continuum of care.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.

· Competency 5: Apply professional, scholarly communication strategies to lead patient-centered care.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

· Complete any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

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Criterion 1

Design patient-centered health interventions and timelines for a selected healthcare problem.

Distinguished

Designs patient-centered health interventions and timelines for a selected healthcare problem that includes community resources.

Proficient

Designs patient-centered health interventions and timelines for a selected healthcare problem.

Basic

Designs patient-centered health intervention for a selected healthcare problem.

Non Performance

Does not design patient-centered health interventions and timelines for a selected healthcare problem.

Criterion 2

Consider the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, supporting ideas with the literature.

Distinguished

Considers the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, including ethical questions that generate uncertainty about the decisions made. Ideas are supported by the literature.

Proficient

Considers the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, supporting ideas with the literature.

Basic

Considers ethical decisions.

Non Performance

Does not consider the ethical decisions in designing patient-centered health interventions for a selected healthcare problem or support ideas with the literature.

Criterion 3

Identify relevant health policy implications for the coordination and continuum of care.

Distinguished

Identifies relevant health policy implications for the coordination and continuum of care, based on accurate interpretations of policy provisions and supporting evidence. 

Proficient

Identifies relevant health policy implications for the coordination and continuum of care.

Basic

Identifies health policy implications that are inconsistent with the goals and objectives for the coordination and continuum of care.

Non Performance

Does not identify relevant health policy implications for the coordination and continuum of care.

Criterion 4

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family members.

Distinguished

Describes priorities that a care coordinator would establish when discussing the plan with a patient and family members, including evidence to support ideas.

Proficient

Describes priorities that a care coordinator would establish when discussing the plan with a patient and family members.

Basic

Identifies priorities that a care coordinator would establish when discussing the plan with a patient and family members.

Non Performance

Does not describe priorities that a care coordinator would establish when discussing the plan with a patient and family members.

Criterion 5

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.

Distinguished

Uses the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030. Explains the need for changes to the plan.

Proficient

Uses the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.

Basic

Discusses evaluation but does not use the literature as a guide to compare learning session content with best practices, or does not include how to align teaching sessions to Healthy People 2030.

Non Performance

Does not use the literature on evaluation as a guide to compare learning session content with best practices, and does not include how to align teaching sessions to Healthy People 2030.

Criterion 6

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Distinguished

Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Correctly uses quotes and paraphrasing.

Proficient

Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Basic

Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes, and/or paraphrasing.

Non Performance

Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.

Criterion 7

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Distinguished

Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.

Proficient

Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Basic

Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.

Non Performance

Does not organize content for ideas. Lacks logical flow and smooth transitions.

Criterion 8

Complete any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.

Distinguished

Completes any remaining practicum hours, for a total of 40 hours, along with a detailed description of activities, approved by your preceptor to Capella Academic Portal.

Proficient

Completes any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submits practicum hour documentation to Capella Academic Portal.

Basic

Completes any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Documents activities in Capella Academic Portal, but not detailed.

Non Performance

Total hours submitted does not equal 40 hours. Does not submit practicum hour documentation to Capella Academic Portal.