Medication Errors

Background

Frances Ballentine is the Vice President for Nursing Services at a hospital that has been found with various problems including inefficient process of medication errors’ reporting.  The problems facing the hospital are ineffective leadership and quality issues. The ineffective leadership is indicated by the inconsistent process of reporting medication errors in the procedure manual for each floor, a problem that was identified after Frances carried out her investigation.  In fact, Frances experienced difficulties while compiling her own monthly report on the number and causes of such errors.  This lead to poor quality of healthcare services provided in the hospital. Therefore, the problems seen in the case include; incomplete reporting of medication errors, lack of monthly report on number and cause of errors, no timely incident reports from the hospital’s departments and the reports presented were most of the time incomplete. These issues majorly formed the secondary problems that resulted in poor quality of services. The primary problem experienced in the hospital was inconsistent application of reporting process after medication errors occurred, and these are attributed to lack of effective leadership across the various departments in the hospitals.

Key players identified in the case include the CEO, Frances as the VP for Nursing Services, Ally Ray as quality improvement director, the MEQI (Medication Errors Quality Improvement) team. The players embarked holding various meetings aimed at investigating of the reporting process of medication errors so as to identify the problems. The MEQI project team embarked on finding ways to improve the process and organized a special team that had knowledge of the process.  The meeting between France and MEQI team members also decided to clarify the present knowledge of the entire process.  The team established a Medication Error Reporting Chart as solution to the problems, and later embarked on implementing the improved process, which was supported by an online training to familiarize nurses with it. Coming up with a cause-and-effect program was an important step taken by the team.

Outcome

The adoption of the new medication error reporting policy, involving PDCA Cycle, and two check sheets is aimed at improving the process. The process requires improved leadership, especially in training and guiding the human resources on how the new policy is to be applied. The outcomes after the adoption of the new policy, including a cause- and –effect chart, should be improved quality of nursing services provided by the hospital. Outcomes in healthcare involve the resulting patients’ health status (Buchbinder, 2012).  Quality involves the technical management of patient’s health and illnesses, and the interpersonal relationship management between healthcare providers and the patient (Buchbinder, 2012). The second aspect relates to the leadership quality among nursing management, a position that is occupied by Frances as the Nurses’ VP.  The adoption of the new policy should ensure that the process of medication error reporting is consistent in the various departments of the hospital. The reporting of the errors should be complete and done on monthly basis so that to maintain consistency.

Moreover, the new policy should also be communicated throughout the hospital so that they the required quality of nursing health services is improved across board. The online training programs have to reach all the nurses in the department so that implementation process of the new policy achieves the required quality.  Quality improvement team under the guidance of QI director should ensure that the health outcomes required are achieved in the hospital. The investigation done by the various teams in the hospital where the reporting process was shown to be inconsistent aligns with the need for combined efforts of various stakeholders and their views in understanding healthcare quality.  Frances position as the VP for Nurses involved technical management and thus, the reason for being tasked by the CEO to oversee the improvement of quality especially while reporting medication errors.  The meetings held by the MEQI project team whose members included the six hospital units and pharmacy representatives indicates the required integration of multiple stakeholders , since their divergent views would result to development of quality process of reporting in the organization.  Health technical management pays attention to the clinical performance of providers of healthcare services while interpersonal relationship management highlights the combined efforts of patients and providers for improved services production (Buchbinder, 2012).  These forms part of the required leadership related outcomes that

Solution

 The major problems identified in the case involve leadership and quality. The solution for these problems has to be based on improved organizational effectiveness and healthcare quality in the various departments of the hospital. Leadership effectiveness will ensure that there is a continuous quality improvement to deal with inefficiencies in the medication error reporting process. This requires a strategy to be adopted by Frances with support of the CEO and other departments in the hospital.  Strategy involves the philosophy or framework, various tactical processes and quality improvement tools. The strategy will ensure that the established framework considers the various problems identified in the investigation including lack of complete and timely reporting. The causes of such problems have to be identified early on before they greatly affect the healthcare outcomes in future.  The medication error reporting process should incorporate a cause-and-effect diagram, before being adopted in the various departments in the hospital. A cause-and-effect diagram is an important tool since it enables nursing management in a hospital to identify the various problems and the probable causes in format that is well structured (Buchbinder, 2012). The application of a frequency chart in the framework such as Pareto chart will ensure that the number of occurrences of the medication errors is tracked, and this will be important in the process of data analysis. The quality improvement strategy to be adopted by the hospital management has to align with the desired health outcomes for the patient.

 A framework that is not aligned with the continuous quality improvement cannot withstand the changes in patient’s health needs. The process of report compilation has to done within the set timelines, a month in this case, while ensuring that all the departments adhere to the various provisions of the process.  For the best health outcomes to be achieved, the hospital leadership should ensure that Continuous Quality Improvement efforts are employed by nurses in all the departments if the hospital.  Quality should be regarded as a major strategic priority in need of executive leadership and therefore, training the staff in quality methods should be part of the organizational culture (Buchbinder, 2012). Quality in health outcomes will be attained if the hospital management trains the nurses in all units about the improved process of reporting medication errors.

 

 

 

 

Reference

Buchbinder, S. B. (2012). Introduction to health care management. Burlington, Mass: Jones et Bartlett Learning.