Medical Errors: Root Cause Analysis

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As much as we try to prevent them, medication errors happen everyday. It is especially common in skilled nursing facilities because many of them still use paper charts for medication administration or documentation and do not have access to the newer technology that other medical facilities do.

According to a study performed in 2014, medication distribution technology has been proven to be effective in automatically detecting medication errors so that nurses can have more of an opportunity to focus on their patients. Working on a long-term care unit, most of my time is spent passing medications and doing treatments since I have 19 residents to tend to. Depending on how “smooth” the night goes, I sometimes do not get a chance to spend that extra time with my residents as I would like to. This medication distribution technology includes a mobile medication dispensing cart for long-term care units. The medications would be pre-packed for each patient by the pharmacy and able to be dispensed when needed. This would allow nurses to provide more one-on-one time with their patients while also increasing the prevention of medication errors. It also will help to lighten the nurses’ workload. Research shows that these mobile medication cart have been successful. Medication error rates decreased from 2.9% to 0.6% (Baril, Gascon & Brouillette, 2014).

Reference

Baril, C., Gascon, V., & Brouillette, C. (2014). Impact of technological innovation on a nursing home performance and on the medication-use process safety. ​Journal of Medical Systems​, ​38​(3), 1–12. https://library.neit.edu:2404/10.1007/s10916-014-0022-4 #2

Adverse drug effects due to medication errors are estimated to cost the United States $2 billion every year. After reviewing patient reports and reviewing charts, it was discovered that 44% of these occur after the prescription was written. These errors were found to be from registered nurses, licensed practical nurses and pharmacy technicians. Therefore, the problem comes from administration of the medication. However, these numbers only account for the errors that are actually reported. It is the more serious and harmful errors that are recorded, probably because they are harder to hide. The Health

Care Finance Administration of the United States made it standard for hospitals and skilled nursing facilities to have no more than 5% of medication error rates a year.

In a study conducted in 2014, researchers decided to put a hold on reviewing incident reports and patient charts. Instead, they decided to directly observe medication administration over 20 different hospitals or skilled nursing facilities. Other methods included: attending medical rounds to see if a medication error had occurred, interviewing health care workers to see if they would report anything, testing patients urine to see if they had any unauthorized medications in their system, and comparing medication administration records with the physician’s order (Flynn, Barker, Pepper, Bates & Mikeal, 2014). I think these methods are effective in detecting medication errors as well as having the healthcare workers realize how often these errors actually do occur and that they should always perform their tasks as if they are always being directly observed.

Reference

Flynn, E.A., Barker, K.N., Pepper, G.A., Bates, D.W., & Mikeal, R.L., (2014). Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. ​American Journal of Health-System Pharmacy​, ​59​(5), 436–446. Retrieved from http://library.neit.edu:2084/login.aspx?direct=true&db=ccm&AN=106538546&site=ehost -live #3

Medical errors are a result of a few different causes. We have learned in this week’s reading that these can be caused by technical errors, organizational errors and human errors. Technical errors are caused by an error in the computer system or a malfunction in equipment being used. Organizational error is when an intervention is not thoroughly planned, or not planned at all. It can also be caused by poor communication within the treatment team. Human errors occur when a person carries out an intervention without double checking if it is appropriate for the patient or if they are even using the proper intervention. It is vital to catch the medical error before or as soon as it happens, so that the steps can be taken to avoid adverse effects from occurring, or if they already have, from getting worse.

In a 2015 study, a design was produced to report medical errors through an online system. Once the medical error is reported, the online system identifies the cause and

the damage resulting from the medical error. It is completely anonymous so healthcare providers do not have to be hesitant to use the system. After identifying the cause and damage of the medical error, the system provides feedback. The system recommends ways to prevent the error from reoccurring as well as providing guidelines on how to prevent them (Jeddi & Atoof, 2015). This will be a great asset if introduced in all medical facilities.

Reference

Jeddi, F. R., & Atoof, F. (2015). Improving patients’ care through electronic medical error reporting system. ​Health, Spirituality & Medical Ethics Journal​, ​2​(2), 22–29. Retrieved from http://library.neit.edu:2084/login.aspx?direct=true&db=ccm&AN=108335172&site=ehost -live #4

When a person hears that a medical error has occurred, they automatically think of the worst case scenario. They are concerned for the patient’s safety and they begin to think of the quality of healthcare of the facility that they chose. Between 1985 and 2005, over 21,000 medical errors were reported in the United States and 3% of them were pediatric cases. In a 2018 study, the target participants were parents with children between the ages 3 to 6. The objective was to determine how parents felt about medical errors and if they have every experienced one when it came to their child. More than half of those surveyed stated that the medical errors were caused by physicians. 21% reported that nurses made the medical error, 6% stated it was both the physicians and the nurses, and 21% blamed other members of the healthcare team. As far as the source of the issues, participants reported that they were related to a shortage of nurses, exhaustion from working long hours, physicians not making enough time for their patients, and lack of teamwork and communication. More than half of the parents involved in the study believed that they were also responsible for the errors that occurred. They believe they should be aware of what is going on so that they can identify if something is going wrong (Bektas & Yardimci, 2018). Involvement of patients and their friends or family in medical treatment is helpful in preventing medical errors.

Reference

Bektas, I., & Yardimci, F. (2018). What do parents think of medical errors? ​International Journal of Caring Sciences​, 379–385. Retrieved from http://library.neit.edu:2084/login.aspx?direct=true&db=ccm&AN=129399275&site=ehost -live #5

Medical errors have been ranked third on the Center for Disease Control’s (CDC) list of common causes of death, following heart disease and cancer. Patient safety is always the ultimate goal but it can also be a major challenge for healthcare systems across the world. One factor that has been found to contribute to these errors are poor communications systems. Electronic medical records (EMR) were developed to make it easier for healthcare providers to communicate, but they have not been perfected to solve these communication issues. It is believed that better data collection systems would help to measure each problem contributing to medical errors so that data can be collected in order to detect a pattern.

In a 2014 study, data was collected from eleven countries, regarding patient-reported medical errors. However, it is important to keep in mind that many patients suffer from adverse effects after they are already discharged so it is hard to include them in the data. Many patients see more than one physician in different facilities so the risks of medical errors increase because not all specialists communicate effectively regarding their patient’s plan of care (Schwappach, 2014) . Patients along with their family members, or whoever else accompanies them to their appointments, are the only ones actually present during every appointment, treatment and consultation, etcetera. It is not always guaranteed that they can remember everything that they are told or that goes on within an appointment. Better communication techniques should be placed so that each healthcare provider a patient sees is on the same page.

Reference

Schwappach, D. L. B. (2014). Risk factors for patient-reported medical errors in eleven countries. Health Expectations, 17(3), 321–331. https://library.neit.edu:2404/10.1111/j.1369-7625.2011.00755.x