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Reflect on your experiences as a health care professional. Use current literature to compare and contrast your experiences with a specific focus on:

1.How the principles of clinical governance are / can be used to improve health care systems
2.Your role as an individual staff member in ensuring the quality & safety of healthcare for people in your care
3.How you can empower consumers to take a more active role in their healthcare experience

The Organization for Economic Co-operation and Development and Patient Safety and Quality Indicator Framework

Despite the commendable work healthcare institutions do in improving the health care outcomes of patients across the globe, there has been growing concerns as to whether the care is given meet the patient's minimum safety and quality standards (Sammer, Lykens, Singh, Mains, & Lackan, 2010). When patients seek healthcare in healthcare facilities, they do in the expectation that their health care conditions will be eliminated and possibly completely cured. However, this is not always the case. Most are the times when patients and patients’ families will raise complaints against the medication they are accorded, the procedures of medication, and how they are handled by healthcare practitioners. As such, patient quality and patient safety indicators are very critical at monitoring and evaluating patient healthcare outcomes and safety to ensure that patients receive safe and quality healthcare.

For countries under the Organization for Economic Co-operation and Development (OECD), a comparable and formidable patient safety and quality indicator framework have been advanced to aid these countries to monitor and evaluate the same at their respective healthcare systems (McLoughlin, et al., 2006).  In their findings, McLoughlin, et al., (2006) included medication errors to be one of the most critical patient safety concerns and indeed posits as a formidable patient quality and safety indicator. Medication errors occur at the medication ordering and administration phase of patient care. These errors have been showcased by empirical research to advance adverse health outcomes to patients. To this end, this paper will extensively discuss medication errors as a patient safety concern by way of defining it and extrapolating how it can be used to evaluate care in a given healthcare setting. Moreover, the paper will move ahead to utilize medication errors as a yardstick of solving a clinical problem; depression through 3 small-scale PDSA quality cycles in a healthcare facility setting.

According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) medication error is under sentinel events category classification. Sentinel events are medical events that ought not to happen (McLoughlin, et al., 2006). To this end, medication errors as a patient safety indicator have a numerator that is composed of facets such as the number of patient deaths, coma, paralysis, and functionality loss. Due to the sentinel event aspect, medication errors do not have and applicable denominator.  However, if in case medication error is applied to a healthcare facility setting, a suitable denominator should be utilized to help relate rates between different states or healthcare facilities (McLoughlin, et al., 2006).

Defining Medication Errors as a Patient Safety Concern

Although clinical therapeutics has had remarkable healthcare outcomes for patients with different diseases, an increment in risks such as medication error has accompanied these benefits. There is no precise definition of medication error. However, Lisby, Nielsen, Brock, Mainz (2010) found 26 varying definitions of medication error in a literature review. Aronson, (2009) define medication error as an error that can either be of commission or omission that takes place at any stage along the patient’s medication pathway. The United States National Coordinating Council for Medication Error Reporting and Prevention [2018] describe a medication error as:

“Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health  care professional, patient, or consumer. Such eventsmay be related to professional practice,health care products, procedures,and systems,including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration,  education, monitoring, and use”

This medication error defination is rather broad but suggests that medication errors are indeed preventable at various levels in the provision of both primary and secondary healthcare. The patient's medication pathway normally starts off when clinicians prescribe medication and stop when medication is actually received by the patient.  In case patients are prescribed medications wrongly, they are likely to suffer preventable adverse drug event (ADE). ADE is the harm patients undergo though as a result of being exposed to wrong medication such as drug reactions, poor quality of life, drug-drug interaction, and declined efficacy (Alexopoulou, et al., 2008).

Garrouste-Orgeas, et al., (2012) points out that several approaches are used to classify medication errors, one of them being classification based on the stage of the patient’s medication pathway such as dispensing, prescribing, transcribing, monitoring and administration. Secondly, medication error can be classified by according to the types of medication errors that happen. These include incorrect medication, administration route, prescription, and frequency. Thirdly, medication errors can be classified according to whether medication errors happen from mistakes done during planning such as rule-based mistakes as well as errors committed during the implementation of well-strategized procedures such as memory-based errors and action-based errors.

From these classifications, it is vivid that medication errors constitute a formidable indicator for both patient quality and patient safety outcomes in a healthcare facility setting. Moreover, medication errors cut across the medical procedure processes and significantly influence ultimate patient outcomes. As a patient quality indicator, it exposes the competence as well as the incompetence of healthcare practitioners in the execution of their healthcare practice with regard to medication general administration [Agency for Healthcare Research and Quality, 2018].

Classification of Medication Errors

Inch, Watson, Anakwe-Umeh (2012) observe that medication errors estimation and measurement as a patient safety indicator is quite a challenging task because of the different definitions as well as classifications systems employed by different healthcare systems. In most cases, the denominator used such as specific medication, patient or prescription is responsible for the different rates obtained. Moreover, this challenge is compounded by there being extensive deviations of healthcare systems used by different healthcare organizations as well as there being different incident reporting systems.  These concerns are manifested through different error prevalence rates reported across the globe. [World Health Organization; Medication Errors, 2018]  

In the United Kingdom, for instance, an empirical research established that 12% of patients receiving primary care have a likelihood of being impacted by either monitoring or prescribing medication error during any given year. Older persons of 75 years and above are worst hit as this rate as it rises to 38% while for patients taking 5 or more drugs in any given year the rate is 30% (Avery, et al., 2012). In yet another study in Sweden, medication error rate was established to be 42% with two-thirds of the reported cases being related to failures of healthcare practitioners to indicate treatment objective and purpose on prescriptions. In the same study, 1 % of medical errors were related to incorrect dose (Claesson, Burman, Nilsson, Vinge, 2008).

In an investigation of Saudi Arabia’s medication error rate, Khoja, et al., (2011) found out that at least one-fifth of patients under primary care received medication with massive prescription errors even though few prescriptions were found to be of an alarming nature. In Mexico, a study by Zavaleta-Bustos, Castro-Pastrana, Reyes-Hernández, López-Luna, and Bermúdez-Camps, (2008) noted that 58% of medication prescriptions had errors in which case dosage regimen was found to be the most prevalent at 27.6%. Garfield, Barber, Walley, Willson, and Eliasson (2009) in a systematic review assessed medication error rates by categorizing medication usage processes in which case the study established medication error rate of 3% during dispensing while failure to make reviews for repeat medications stood at 72% of all cases. The study also established there were challenges with primary and secondary care integration with 77% medication error rate reported for outpatient recommendations to general healthcare providers while discrepancies during discharge stood at 43% to 60% of medication substances vividly signifying huddles at care transitioning

Medication errors are associated with several factors.  While examining the patient reported medication errors in seven countries in a survey, the Commonwealth Fund International Health Policy established that 11% of primary care patients experiencing the same risk factors included factors such as poor care coordination, multimorbidity, cost barriers, and hospitalization (Lu, & Roughead, 2011). Bourgeois, Shannon, Valim, Mandl (2010) assert that medication errors emanate from increasing number of medication a patient is subjected in, ages of patients with older persons and children being the most affected, prescription of specific medications targeting particular healthcare conditions.  By and large, Smeulers, et al., 2015) observe that different healthcare stakeholders, healthcare workplace environment and different medications nature contribute to medication errors through different ways.

Medication Errors as a Patient Quality Indicator

Although a number of empirical studies have tried to explore ways and means of improving quality of prescription, most studies’ outcomes are not diverse and medication errors have actually attracted the attention of few studies (Fanikos, Jenkins, Piazza, Connors, & Goldhaber, 2014). Medication reviews and reconciliation is one strategy that can be used to improve patient safety with regard to medication errors. Medication review is interested in patient's medical evaluation for purposes of elevating patient's health outcomes besides mitigating adverse medication errors. On the other hand medication reconciliation is concerned with the documentation of definitive list of medicine through care transitions and going ahead to rectify discrepancies [Pharmaceutical Care Network Europe, 2016]. Automation of the medication administration process, healthcare education and training of best practices and prioritizing critical areas can go a long way in minimizing medication errors and subsequently elevating the patient quality and safety outcomes.

The Plan-Do-Study-Act (PDSA) quality cycles structure has been showcased to be very instrumental in advancing improvement in most patients’ quality and safety healthcare indicators (Varkey, et al., 2009). Healthcare quality improvement constitutes an extensive range of tasks and activities with different levels of complexity, statistical and methodological rigor that healthcare practitioners use to structure, utilize and evaluate small-scale interventions. Healthcare practitioners then pinpoint interventions that promise optimal outcomes and replicate them more extensively with the view of improving clinical practice.  Patient quality and safety outcomes are by and large concerned with advancing healthcare that is more safe, effective and patient-centered. To register change and improvement in the patient quality and safety, the PDSA cycle demands healthcare practitioners to ask three questions that inform the improvement process:  What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? By combining the three questions with the PDSA cycle a model of improvement emerges (Curnock, Ferguson, McKay, & Bowie, 2012).

The Improvement Guide, API, 2009.

Solving Medication Error through Small-Scale PDSA quality cycles for Depression Patients

Medication errors through the wrong prescription, dosage, frequency are bound to adversely impact depression patients especially because of their mental illness condition and lack of adequate experience and expertise on mental illnesses by most healthcare practitioners and these factors by extension compromise on patient quality and safety standards.

Fundamental Questions

What are we trying to accomplish?

1. Minimize medication errors amongst depressed patients by at least 50% of all reported cases within a period of the next one year by improving medication handling protocols and procedures.

2. Extensively engage all healthcare stakeholders in quality improvement approaches related to medication error minimization

3. Improving the health facility environment by removing disruptions that contribute to depression medication errors

How will we know that a change is an improvement?

1. Medication error has been  minimized across the entire healthcare facility with all tasks and activities involved in medication handling and administration improved

2. Healthcare stakeholders including healthcare practitioners demonstrate skilled medication management and administration

3. There are proper communication channels and proper drug arrangements

What changes can we make that will result in an improvement?

1. Tighten medication handling protocols and procedures including medication orders, storage, transcribing, prescribing, dispensation, and administration.

2. Healthcare practitioners’ training and education on the impact of medication errors on patient safety outcomes.

3. Improve and promote open communication and arranging medication according to their classifications

 

PDSA CYCLE 1 Objective: Minimization medication errors by at least 70% of all previously reported cases

Plan

The Improvement being sought

Minimize medication errors amongst depressed patients by at least 70% of all previously reported cases within a period of the next one year

Time planning

 Have a hospital Time Planner Template

Measure of patient safety and quality indicators

Percentage of reduced medical errors as indicated by reduced number of patients and families reporting wrong medication prescription

Select change

Tighten depression medication handling protocols and procedures

Do

Implement change

Ensure proper protocols and procedures in medication handling processes through proper ordering, transcribing, proper documentation and labeling and prescription administration

Study

Evaluate change

Process: Improved depression medication handling protocols and procedures

Outcome: Number of patients reporting right medication outcomes

Act

Adopt, reject or modify the change plan

Positive improvement as evidenced by reduced depression medication errors by 50% of previous reported incidences.

Increased number of patients and families reporting right medication prescription

PDSA CYCLE 2 Objective: Improve healthcare practitioners’ skills and expertise to minimize medication error by 80% of previously reported cases

Plan

The Improvement being sought

Improve healthcare practitioners’ skills and expertise to minimize medication error by 80% of previously reported cases

Time planning

 Have a hospital Time Planner Template

Measure of patient safety and quality indicators

% of reduced medical errors as indicated by reduced number of patients and families reporting wrong medication prescription

Select change

Proper patient healthcare condition diagnosis to properly inform correct prescription.

Healthcare practitioners’ training and education on the impact of medication errors on patient safety outcomes.

Do

Implement change

Tighten patient treatment procedures

Train and educate healthcare practitioners

Study

Evaluate change

Process: Improved patient diagnosis

Outcome: Number of healthcare practitioners that can properly prescribe depression medications leading to reduced medication error

Act

Adopt, reject or modify the change plan

Positive improvement as evidenced by reduced depression medication errors by 60% of previous reported incidences.

Increased number of patients and families reporting right medication prescription

Estimating and Measuring Medication Errors as a Patient Safety Indicator

PDSA CYCLE 3 Objective: Improving the health facility environment by removing disruptions that contribute to depression medication errors and minimizing the same by at least 90% of all previously reported cases

Plan

The Improvement being sought

Improving the health facility environment by removing disruptions that contribute to depression medication errors  and minimizing the same by at least 90% of all previously reported cases within a period of the next one year

Time planning

 Have a hospital Time Planner Template

Measure of patient safety and quality indicators

% of reduced medical errors as indicated by reduced number of patients and families reporting wrong medication prescription

Select change

Establish effective communication channels for healthcare staff handling depression patients’ medication.

Do

Implement change

Facilitate open communication between healthcare practitioners and a conducive working environment free from disruptions.

Study

Evaluate change

Process: Improved medication communication protocols and procedures

Outcome: Number of patients reporting right medication outcomes

Act

Adopt, reject or modify the change plan

Positive improvement as evidenced by reduced depression medication errors by 70% of previous reported incidences.

Increased number of patients and families reporting right medication prescription

Conclusion

Indeed, patient quality and patient safety are critical at in holding the medical profession accountable by way of demanding healthcare stakeholders meet minimum patient safety and quality standards. When patients seek healthcare in healthcare facilities, they do in the expectation that their health care conditions will be eliminated and possibly completely cured. However, medication concerns such as medication errors have continuously acted to curtail the attainment of quality patient outcomes. With proper healthcare facility medication administration, these errors are not bound to occur. Moreover, healthcare facilities ought to draw from the potential of PDSA quality cycles hold to inform improvements in medication administration to minimize medication errors.

References

Alexopoulou, A., Dourakis, S. P., Mantzoukis, D., Pitsariotis, T., Kandyli, A., Deutsch, M., &

Archimandritis, A. J. (2008). Adverse drug reactions as a cause of hospital admissions: a 6-month experience in a single center in Greece. European journal of internal medicine, 19(7), 505-510.

Avery, T., Barber, N., Ghaleb, M., Franklin, B. D., Armstrong, S., Crowe, S., ... & Serumaga, M.

(2012). Investigating the prevalence and causes of prescribing errors in general practice. London: The General Medical Council: PRACtICe Study.

Agency for Healthcare Research and Quality (2018). Medication Errors and Adverse Drug Events Available from https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events

Aronson, J. K. (2009). Medication errors: definitions and classification. British journal of clinical pharmacology, 67(6), 599-604.

Bourgeois, F. T., Shannon, M. W., Valim, C., & Mandl, K. D. (2010). Adverse drug events in the outpatient setting: an 11?year national analysis. Pharmacoepidemiology and drug safety, 19(9), 901-910.

Curnock, E., Ferguson, J., McKay, J., & Bowie, P. (2012). Healthcare improvement and rapid PDSA cycles of change: a realist synthesis of the literature. NHS Education for Scotland.

Claesson, C. B., Burman, K., Nilsson, J. L. G., & Vinge, E. (2008). Prescription errors detected by Swedish pharmacists. International Journal of Pharmacy Practice, 3(3), 151-156.

Fanikos, J., Jenkins, K. L., Piazza, G., Connors, J., & Goldhaber, S. Z. (2014). Medication use evaluation: pharmacist rubric for performance improvement. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 34(S1), 5S-13S.

Garrouste-Orgeas, M., Philippart, F., Bruel, C., Max, A., Lau, N., & Misset, B. (2012). Overview of medical errors and adverse events. Annals of intensive care, 2(1), 2.

Garfield, S., Barber, N., Walley, P., Willson, A., & Eliasson, L. (2009). Quality of medication use in primary care-mapping the problem, working to a solution: a systematic review of the literature. BMC Medicine, 7(1), 50.

Inch, J., Watson, M. C., Anakwe-Umeh, S., & Yellow Card Study Collaboration. (2012). Patient versus healthcare professional spontaneous adverse drug reaction reporting. Drug Safety, 35(10), 807-818.

Khoja, T., Neyaz, Y., Quresh, N. A., Mogzoub, M. A., Haycox, A., & Walley, T. (2011).

Medication errors in primary care in Riyadh city, Saudi Arabia.

Lisby, M., Nielsen, L. P., Brock, B., & Mainz, J. (2010). How are medication errors defined? A systematic literature review of definitions and characteristics. International Journal for Quality in Health Care, 22(6), 507-518.

Lu, C. Y., & Roughead, E. (2011). Determinants of patient?reported medication errors: a comparison among seven countries. International journal of clinical practice, 65(7), 733-740.

McLoughlin, V., Millar, J., Mattke, S., Franca, M., Jonsson, P. M., Somekh, D., & Bates, D.

(2006). Selecting indicators for patient safety at the health system level in OECD countries. International Journal for quality in health care, 18(suppl_1), 14-20.

National Coordinating Council for Medication Error Reporting and Prevention (2018). About Medication Errors; What is a Medication Error? Available from https://www.nccmerp.org/about-medication-errors

Pharmaceutical Care Network Europe. Medication review definition approved. 2016 Available from https://www.pcne.org/news/35/medication-review-definition-approved Smeulers, M., Verweij, L., Maaskant, J. M., de Boer, M., Krediet, C. P., van Dijkum, E. J. N., &

Vermeulen, H. (2015). Quality indicators for safe medication preparation and administration: a systematic review. PLoS One, 10(4), e0122695.

Sammer, C. E., Lykens, K., Singh, K. P., Mains, D. A., & Lackan, N. A. (2010). What is patient safety culture? A review of the literature. Journal of Nursing Scholarship, 42(2), 156-165.

Varkey, P., Sathananthan, A., Scheifer, A., Bhagra, S., Fujiyoshi, A., Tom, A., & Murad, M. H.

(2009). Using quality-improvement techniques to enhance patient education and counseling of diagnosis and management. Quality in primary care, 17(3).

World Health Organisation (2018) Medication Errors: Medication Errors Technical Series on Safer Primary Care Available from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643eng.pdf;jsessionid=DF494384783433444C016C6B0B8D19D9?sequence=1

Zavaleta-Bustos, M., Castro-Pastrana, L. I., Reyes-Hernández, I., López-Luna, M. A., & Bermúdez-Camps, I. B. (2008). Prescription errors in a primary care university unit: urgency of pharmaceutical care in Mexico. Revista Brasileira de Ciências Farmacêuticas, 44(1), 115-125.

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