POLICY PROPOSAL PRESENTATION LEARNER’S NAME CAPELLA UNIVERSITY NHS6004: HEALTH CARE LAW AND POLICY INSTRUCTOR NAME JANUARY 1, 2020 Hello, and welcome to today’s presentation on the policy proposal for managing medication errors. This presentation has been designed to give you, the stakeholders, all the relevant information about the need for an institutional policy that will reduce medication errors at Mercy Medical Center. We will also discuss the scope of the proposal, strategies to resolve medication errors, and stakeholder involvement in the implementation of these strategies. 1 Presentation Outline ■ Policy on Managing Medication Errors ■ Need for a Policy ■ Scope of the Policy ■ Strategies to Resolve Medication Errors ■ Role of the Hospital Staff ■ Positive Impact on Working Conditions ■ Issues in the Application of Strategies ■ Alternative Perspectives on Mitigating Medication Errors ■ Stakeholder Participation We will begin by understanding the features of the policy on managing medication errors. We will examine the need for a policy and determine its scope. The policy will revolve around two strategies to resolve medication errors. We will identify the role of members of the hospital staff who will implement the strategies. We will examine the potential positive impact of the strategies on the working conditions of the staff. We will also delve into possible barriers that could arise during the application of the strategies. Next, we will discuss alternative perspectives for resolving medication errors. Finally, we will look at the stakeholder involvement in implementing these strategies. 2 Policy on Managing Medication Errors ■ Analyzing medication error trends and addressing shortfalls regularly ■ Establishing automated dispensing cabinets to manage medication ■ Training hospital staff and pharmacists on medication error prevention ■ Educating patients on potential areas of medication error The policy guidelines presented here comply with state and federal laws. Centers for Medicare & Medicaid Services mandates the implementation of evidence-based initiatives to improve the quality of health care by analyzing the condition of patient safety and managing medication errors (Centers for Medicare & Medicaid Services, 2017). Mercy Medical Center intends to regularly conduct a thorough analysis of medication error trends as a quality measure and to identify gaps in existing medical processes. To comply with the Code of Maryland Regulations, the hospital will conduct training sessions to educate and train health care professionals such as doctors, nurses, and hospital support staff to manage and minimize medication errors. An internal staff committee will be formed to regularly review patient safety standards. The hospital will also encourage timely and accurate reporting of medication errors, which would help in trend analysis of these errors (Code of Maryland Regulations, n.d.). As per the new policy, the hospital will install automated dispensing cabinets to efficiently manage medication and to reduce dispensingrelated medication errors (Darwesh et al., 2017). 3 Need for a Policy ■ Increase in medication errors from 2015 to 2016 by 50% ■ Medication errors can increase the cost of health care ■ Medication errors can cause significant harm to patients ■ Managing medication errors is essential for quality improvement Medication errors can endanger patient safety and public health. Medication errors can cause significant harm to patients and endanger their lives. From 2015 to 2016, Mercy Medical Center has seen a 50% increase in medication errors in its medical and surgery units. Medication error incidents need additional care interventions and resources, which could lead to an increase in expense for medical practitioners and a decrease in the efficiency of health care services. Medication error incidents could also negatively affect the hospital’s reputation. Managing medication errors ensures patient safety and reduces potential risks to a patient’s life, thereby reflecting highquality patient care (Kavanagh, 2017). 4 The policy is applicable to: Nursing and medical staff Scope of the Policy Emergency and allied care practitioners Pharmacists and pharmacy staff Patients and family members Board members It is necessary to identify the group of stakeholders in order to analyze and understand their expectations and interests. The policy is applicable to medical and nursing staff, emergency care staff, and pharmacists and pharmacy staff (Kavanagh, 2017; Ferencz, 2014) because they prescribe, administer, and dispense medication. It caters to patients and their family members by conducting training programs to increase their awareness of medication errors. The policy is also applicable to the board members of the hospital. Their involvement in financial decisions and role allocation is important when promoting safe and quality health care (Parand et al., 2014). 5 Strategies to Resolve Medication Errors (1) Medication error analysis ■ Uses failure mode and effects analysis ■ Evaluates potential vulnerabilities in medical processes ■ Identifies actions that could reduce potential errors ■ Mitigates the risk and impact of repeated errors Medication errors can pose serious risks to patient safety; however, learning from these errors can help improve care interventions and reduce recurrences. Each error reported is an opportunity for practitioners to develop countermeasures or to avoid the repetition of errors as well as mitigate the impact of errors. Under the failure mode and effects analysis technique defined by Weant et al. (2014), a multidisciplinary committee commissioned by Mercy Medical Center can review medication delivery and administration processes vulnerable to errors, the steps in each process, possible failures, reasons for failures, and possible impact (Institute for Healthcare Improvement, n.d.). This committee can observe shortfalls and organize errors as per the urgency. Accordingly, the committee can recommend actions to reduce the possible errors in the medication process. The analysis will end with an evaluation of the prescribed actions for improvement (Centers for Medicare & Medicaid Services, n.d.). 6 Strategies to Resolve Medication Errors (2) Automated dispensing cabinets ■ Store, dispense, and electronically track drugs ■ Assist the medical center in profiling patients ■ Reduce the time taken to retrieve medication ■ Track inventory on a real-time basis Nursing staff, who are usually preoccupied with heavy workloads, will benefit greatly from the automated dispensing cabinets. Automated dispensing cabinets facilitate the safe delivery of care and reduce retrieval times for medication (Rochais et al., 2014). 7 Role of the Staff ■ Identify the right workflow ■ Maintain optimum inventory ■ Establish procedures for accurate withdrawal of medication ■ Establish guidelines for reporting errors ■ Conduct training The staff of Mercy Medical Center will play an important role in the implementation of the new policy. The Chief of Medicine, along with the board members, will have to identify the right workflow and establish a reporting hierarchy. This will help staff members identify the contact persons to whom they must report an error. The nursing staff will be responsible for a double-check mechanism to restock medication. This will ensure efficient inventory management, especially when hospitalists use the automated dispensing cabinets. The Chief of Medicine, along with other department heads, will be responsible for establishing an accurate withdrawal procedure to mitigate erroneous administration of drugs. A quality committee comprising key administrative personnel, nursing staff, and doctors will establish the guidelines and protocols for reporting errors. These guidelines will also help increase staff awareness of the different degrees of medication errors and their consequences. 8 Positive Impact on Working Conditions ■ Improvement in the safety of medication system ■ Mitigation of future errors ■ Optimum stock of medication ■ Reduced reliance on verbal orders The new policy on the management of medication error will, in a pervasive manner, improve the safety of the medication system. The use of automated dispensing cabinets will reduce the scope of mismanagement in the prescription and administration of drugs. Analysis of medication errors will help identify the bottlenecks in the medication administration and dispensing procedures, which will help avoid errors in future (Weant et al, 2014). Automated dispensing cabinets help in managing the inventory of drugs efficiently and will ensure that there is always an optimum stock of medicines for corresponding patient profiles (Rochais, et al, 2014). A standardized operating procedure will reduce the need for staff to rely on verbal orders. 9 Issues in Application of Strategies ■ Irregular or inaccurate documentation ■ Incorrect restocking of automated dispensing cabinets ■ Inefficient functioning of dispensing cabinets ■ Complexities in point-of-care drug order entry A few precautions need to be taken in order to successfully implement the strategies. Medication errors must be documented regularly to perform effective analysis. Additionally, verbal reporting of errors must be discouraged because such reporting can result in incorrect documentation or underreporting of errors; dissuading such reporting increases the scope for improvement of patient safety (Elden & Ismail, 2016). A conducive environment is essential for the implementation of these strategies. Dependence on a one-size-fits-all dispenser may lead to the system operating below expectations. Point-of-care drug entries made by prescribers can become complicated because of interface-based complexities. A prescriber must choose from a large variety of drugs, brands, and dosages for drug profiling, which is a tedious task (Ferencz, 2014). 10 Alternative Perspectives on Mitigating Medication Errors ■ Using robotic systems for medication distribution ■ Linking supply ordering with medication distribution system A novel alternative to mitigating medication errors is to use robotic systems for medication distribution. This is a high-end, fully automated medication distribution system, unlike the smaller automated dispensing cabinets proposed for Mercy Medical Center. A robotic system is incompatible with Mercy Medical Center as it is prohibitive in terms of the cost. There is also a lack of definitive evidence indicating that dispensing errors and inventory management issues can be resolved effectively using this technology (Rodriguez-Gonzalez et al., 2019). Smaller care centers link the ordering of supplies with a medication distribution system in order to ensure a continuous supply of medication (Rovers & Mages, 2017). This would also help prevent overstocking. However, implementing the technique would require a complete overhaul of the current supply ordering system, which, given the large size of the center, is not recommended. Therefore, this technique is not feasible for Mercy Medical Center. 11 Stakeholder Participation ■ Key administrative personnel will form a quality committee ■ Nursing staff will identify processes in which most medication errors occur ■ Pharmacists should ensure strict compliance of stocking and dispensing policies ■ Board members will ensure transparency and efficiency ■ Patients and family members will provide feedback for improvement The key administrative personnel establish role accountability, articulate the organization’s quality improvement norms, and regularly strengthen a culture of safety among the staff. A quality committee comprised of key administrative personnel can ensure an exchange of expertise between members of the committee and nursing staff and better monitoring of strategy implementation. This committee will ensure that the medical, nursing, emergency care, and pharmacy staff adhere to federal and state quality and safety benchmarks (Parand et al., 2014). The multidisciplinary committee should also involve the main nursing staff as they have firsthand experience in dealing with medication administration problems. They will be able to recognize the shortfalls that lead to errors. Additionally, pharmacists can cross-check with prescribers for discrepancies in medication orders while receiving prescriptions (The Health Foundation, 2012; Ferencz, 2014). 12 References (1) Agency for Healthcare Research and Quality. (2017). Guide to patient and family engagement in hospital quality and safety. https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html Centers for Medicare & Medicaid Services. (n.d.). Guidance for performing failure mode and effects analysis with performance improvement projects. https://cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/GuidanceForFMEA.pdf Centers for Medicare & Medicaid Services. (2017). Patient safety standards. https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/Patient-Safety/MQI-Patient-Safety.html Code of Maryland Regulations. (n.d.). Hospital patient safety program. http://qups.org/med_errors.php?c=internal&id=172 Darwesh, B. M., Machudo, S. Y., & John, S. (2017). The experience of using an automated dispensing system to improve medication safety and management at King Abdul aziz University Hospital. Journal of Pharmacy Practice and Community Medicine 3(3), 114–119. http://doi.org/10.5530/jppcm.2017.3.26 Elden, N. M. K., & Ismail, A. (2016). The importance of medication errors reporting in improving the quality of clinical care services. Global Journal of Health Science, 8(8), 243–251. https://doi.org/10.5539/gjhs.v8n8p243 Ferencz, N. (2014). Safety of automated dispensing systems. U.S. Pharmacist. https://www.uspharmacist.com/article/safety-of-automated-dispensing-systems Institute for Healthcare Improvement. (n.d.). Failure modes and effects analysis. http://ucdenver.edu/academics/colleges/medicalschool/facultyAffairs/moc/Forms/Documents/MOCPAP/FailureModes andEffectsAnalysis_IHI.pdf 13 References (2) Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159–165. http://doi.org/10.12968/bjon.2017.26.3.159 Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality and patient safety: A systematic review. BMJ Open, 4(9). http://doi.org/10.1136/bmjopen-2014-005055 Rochais, É., Atkinson, S., Guilbeault, M., & Bussières, J.-F. (2014). Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center. Journal of Pharmacy Practice, 27(2), 150–157. https://doi.org/10.1177/0897190013507082 Rodriguez-Gonzalez, C. G., Herranz-Alonso, A., Escudero-Vilaplana, V., Ais-Larisgoitia, M. A., Iglesias-Peinado, I., & SanjurjoSaez, M. (2019). Robotic dispensing improves patient safety, inventory management, and staff satisfaction in an outpatient hospital pharmacy. Journal of Evaluation in Clinical Practice, 25(1), 28–35. https://www.ncbi.nlm.nih.gov/pubmed/30136339 Rovers, J. P., & Mages, M. D. (2017). A model for a drug distribution system in remote Australia as a social determinant of health using event structure analysis. BMC Health Services Research, 17(1), 677. https://www.ncbi.nlm.nih.gov/pubmed/28946918 The Health Foundation. (2012). Evidence scan: Reducing prescribing errors. https://health.org.uk/sites/default/files/ReducingPrescribingErrors.pdf Weant, K. A., Bailey, A. M., & Baker, S. N. (2014). Strategies for reducing medication errors in the emergency department. Open Access Emergency Medicine, 6, 45–55. https://doi.org/10.2147/OAEM.S64174 14 1 Policy Proposal Name Institutional affiliation Course Instructor Date 2 Mercy Medical Center has been recognized as the most preferred choice for healthcare. Nonetheless, it has a number of areas that require improvement. According to the Centers for Medicare and Medicaid Services (n.d.), medication errors, especially in the surgery and medical units, have been exacerbated by about 50% from 2015 to 2020. Persistent medication errors are attributed to extended hospital stays alongside a high rate of morbidity and mortality. Such errors might result in a high cost of healthcare services. The occasions or rather incidences that heighten medication errors can only be mitigated when adequate resources and interventions (Institute for Healthcare Improvement, n.d.). As such, they pose adverse impacts to healthcare institutions, such as reducing the efficiency of care services delivered. Owing to the repercussions imposed by medication errors on the care providers and patients, there is a need to come up with an organizational policy that can best address the problem of medication errors. Interventions to Address Medication Errors Automated Dispensing Cabinets Automated dispensing cabinets are medication distribution systems that are computerized and installed in the patient care units. The system typically stores, dispenses, and then tracks drugs electronically at the point of care. According to Blake (2017), if a medical center introduces these particular cabinets, it benefits from accurate patient profiling, reduced time for tracking drugs and tracking inventory on a real-time basis. These state-of-the-art cabinets are designed in such a way that they contain high alert and controlled medications. To access them, one is required to use an identity and a password. Having these cabinets in place means that care providers do not necessarily have to walk long distances to collect the required medication. Medication Error Analysis 3 According to Kavanagh (2017) the vast majority of the medication errors go unnoticed or unreported due to the fear of the care providers to face disciplinary actions. Nonetheless, suppose care providers are provided with an opportunity to learn from these errors. In that case, it is probable that there will be a reduction in their recurrence, which will improve care interventions. Blake (2017) asserts that every reported error in a healthcare setting presents an opportunity for the development of a counter-intervention that will aid in preventing the recurrence of the same error. According to Blake (2017), a healthcare institution or rather system with the highest likelihood of medical errors should be critically evaluated. One of the most effective approaches for analyzing the common incidences attributed to medication errors is the failure mode and effects analysis. In adopting this model of analysis, a medical center can be in the position to commission the formation of a multidisciplinary committee responsible for overseeing and reviewing the various processes prone to errors (Institute for Healthcare Improvement, n.d.). Depending on the kind of shortcomings identified, the committee in place classifies the medication errors based on the urgency and priority they have to be addressed. Moreover, the committee will be mandated to review the process, the possible elements that could be wrong, the reasons behind them, and the presumed impacts. The committee will then proceed to recommend the best actions or rather interventions for reducing the possible errors in the process (Center for Medicare and Medicaid Services, n.d.). After the analysis, the committee will wrap up with evaluating the prescribed interventions for improvement. Impacts of Environmental Factors Successful implementation of these interventions can be affected by certain environmental attributes. The efficiency of medication error analysis can be affected in the event 4 that the error incidents are underreported. The other gr…
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