Safety Consciousness/Risk Management Medication Errors in Surgical Wards

Introduction

Identifying and minimising safety risks in the healthcare industry is crucial, especially in high-stress settings like operating rooms. In the case of pharmaceutical errors, this is especially true. Due to the potentially significant consequences for patients, it is crucial to prevent medication errors (Rodziewicz & Hipskind, 2020). Maintaining patient safety and high-quality care necessitates, a systematic approach that includes risk assessment, knowledge of system barriers and facilitators, and creating evidence-informed recommendations with pragmatic implementation.

Risk Assessment Stage

A rigorous approach was used in the surgical ward to estimate the likelihood of medication mistakes. The initial step involved gathering data, which included reviewing employee interviews, patient records and accounts of incidents. Incident reports also highlighted patterns and provided insights into specific errors, near-misses, and unfavourable events from the preceding year (Hasanspahi et al., 2020). Staff interviews shed qualitative light on the challenges experienced by medical personnel when dispensing pharmaceuticals and highlighted the primary causes of errors.

 A comprehensive understanding of safety concerns was provided by reviewing patient records, which revealed medication-related difficulties that would not have been mentioned in event reports (Keers et al., 2018). Root cause analysis was crucial in identifying the core causes of these errors and correcting systemic, interpersonal, and communication-related problems (American Society for Quality, 2023). To ensure the assessment followed the best standards, a thorough examination of the literature was done, emphasising recommendations from agencies like the Institute for Safe Medication Practices (ISMP), which offered insightful information on the safety of medications in surgical settings (Clarke et al., 2020). The results of this thorough analysis provided a thorough understanding of the safety hazards associated with medication errors in the surgical ward, including their underlying causes and motivating variables.

System barriers and facilitators

Barriers

Firstly, a notable barrier was the need for standardised medication administration and reconciliation procedures. Varied practices among healthcare providers, particularly in medication labelling and double-checking, contributed to confusion and elevated error risks, emphasising the need for enhanced standardisation (Kuitunen et al., 2021). Secondly, the surgical ward's inherent high-stress environment, characterised by complex and urgent procedures, introduced distractions, concentration lapses, and cognitive overload, amplifying medication error risks (Rodziewicz et al., 2022). Thirdly, effective communication is paramount for patient safety, especially during handovers and care transitions. The assessment revealed significant communication breakdowns during handovers, increasing the likelihood of medication errors due to critical information oversight. Lastly, patients in the surgical ward often require intricate medication regimens, complicating medication management and elevating the risk of errors, particularly with multiple medications (Methangkool et al., 2018).

Facilitators

Firstly, despite the barriers, the surgical ward benefits from dedicated and highly skilled healthcare professionals committed to patient safety, forming a solid foundation for addressing safety risks effectively (Okloo et al., 2021). Secondly, the surgical ward nurtures a culture with a solid commitment to improvement, openness, and transparency. This willingness to learn from incidents and near misses creates an environment conducive to addressing safety risks and implementing necessary changes (Fencl et al., 2021). Acknowledging these system barriers and facilitators offers a comprehensive understanding of the medication error landscape in the surgical ward, enabling tailored recommendations to tackle these specific challenges effectively.

Recommendations for improvement

Developing evidence-informed recommendations to enhance medication safety in the surgical ward was a pivotal phase of the risk assessment process (Mutair et al., 2021). These recommendations, grounded in literature, change theory, and best practice guidelines, aimed to address identified safety risks effectively. The first recommendation emphasises the need for standardisation was evident, particularly in medication administration and reconciliation procedures. Adhering to ISMP guidelines, this recommendation emphasised uniformity in medication labelling, double-checking, and documentation to reduce confusion and errors (Kron et al., 2018).

Secondly, given the high-stress surgical environment's challenges, staff were to undergo training and simulation exercises. These simulations simulated high-stress scenarios, preparing healthcare providers to manage stress, reduce distractions, and minimise the risk of errors (Sinyard et al., 2022). Thirdly, effective communication was critical, especially during handovers and care transitions. This recommendation included structured handover protocols, checklists, and interprofessional meetings to ensure accurate information exchange, reducing the risk of medication errors (Rosen et al., 2018). Lastly, a robust medication reconciliation process was proposed to maintain accurate medication lists for patients with complex regimens. This process involved comprehensive verification and documentation during admission, transfer, and discharge to ensure a clear medication regimen view (Botros & Dunn, 2019).

These recommendations were evidence-based and in alignment with best practice guidelines from organisations like the ISMP (Clarke et al., 2020). Presenting these recommendations to surgical ward stakeholders, especially the leadership team, was essential for endorsement and support. An implementation plan was collaboratively developed with a multidisciplinary team, and regular updates were provided to ensure staff engagement and accountability in the pursuit of enhanced medication safety.

Evaluation

The evaluation phase measures the effectiveness of the recommendations and their contribution to readiness for leadership in nursing practice. Two critical aspects of the evaluation were identified. Firstly, implementing the recommendations faced initial resistance common in healthcare when altering established routines. Overcoming scepticism and disruption concerns was achieved through ongoing education, feedback loops, and robust support from leadership. Encouragingly, tangible progress was noted through reduced medication errors and related incidents, affirming the efficacy of the new procedures. Secondly, this project significantly strengthened my readiness for leadership in nursing practice. It honed key leadership skills like change management, effective communication, and project execution. Leading a diverse team in implementing these changes emphasised collaborative leadership. Additionally, the project underscored the significance of evidence-based practices and cultivating a culture of safety and improvement within healthcare, preparing for future leadership roles.

Conclusion

In conclusion, the comprehensive process of identifying and addressing safety risks, specifically medication errors, in the surgical ward's point-of-care setting is crucial for ensuring patient safety and delivering high-quality care. The risk assessment stage involves data collection, root cause analysis, and literature review to understand safety risks and their underlying causes. System barriers and facilitators significantly impact safety risks and play a crucial role in addressing these issues effectively. Developing evidence-informed recommendations is the key to effectively mitigating safety risks, guided by best practices and supported by the leadership team. The evaluation phase measures the impact of the recommendations and their contribution to readiness for leadership in nursing practice. This approach ensures healthcare settings continuously improve, providing the highest level of care to patients while preparing future nursing leaders to navigate the complexities of healthcare.

References

American Society for Quality. (2023). What is root cause analysis (rca)?.https://asq.org/quality-resources/root-cause-analysis

Botros, S., & Dunn, J. (2019). Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story. BMJ Open Quality, 8(3), e000363. http://dx.doi.org/10.1136/bmjoq-2018-000363

Clarke, H. A., Manoo, V., Pearsall, E. A., Goel, A., Feinberg, A., Weinrib, A., Chiu, J. C., Shah, B., J. Ladak, S. S., Ward, S., Srikandarajah, S., Brar, S. S., & McLeod, R. S. (2020). Consensus statement for the prescription of pain medication at discharge after elective adult surgery. Canadian Journal of Pain = Revue Canadienne de la Douleur, 4(1), 67-85. https://doi.org/10.1080/24740527.2020.1724775

Fencl, J. L., Willoughby, C., & Jackson, K. (2021). Just Culture: The foundation of staff safety in the perioperative environment. AORN Journal, 113(4), 329-336. https://doi.org/10.1002/aorn.13352

Hasanspahić, N., Frančić, V., Vujičić, S., & Maglić, L. (2020). Reporting as a key element of an effective near-miss management system in shipping. Safety, 6(4), 53. https://doi.org/10.3390/safety6040053

Keers, R. N., Plácido, M., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLoS ONE, 13(10). https://doi.org/10.1371/journal.pone.0206233

Kron, K., Myers, S., Volk, L., Nathan, A., Neri, P., Salazar, A., & Schiff, G. (2018). Incorporating medication indications into the prescribing process. The Bulletin of the American Society of Hospital Pharmacists, 75(11), 774-783. https://doi.org/10.2146/ajhp170346

Kuitunen, S., Niittynen, I., Airaksinen, M., & Holmström, R. (2021). Systemic causes of in-hospital intravenous medication errors: A systematic Review. Journal of Patient Safety, 17(8), e1660. https://doi.org/10.1097/PTS.0000000000000632

Methangkool, E., Tollinche, L., Sparling, J., & Agarwala, A. V. (2018). Communication: Is there a standard handover technique to transfer patient care? International Anesthesiology Clinics, 57(3), 35. https://doi.org/10.1097/AIA.0000000000000241

Mutair, A. A., Alhumaid, S., Shamsan, A., Zia Zaidi, A. R., Mohaini, M. A., Mutairi, A. A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9). https://doi.org/10.3390/medicines8090046

Ocloo, J., Garfield, S., Franklin, B. D., & Dawson, S. (2021). Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: A systematic review of reviews. Health research policy and systems, 19, 1-21. https://doi.org/10.1186/s12961-020-00644-3

Rodziewicz, L.T., Houseman, B., & Hipskind, E.J.. (2022). Medical Error Reduction and Prevention. UK:. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls. Treasure Island (FL): StatPearls Publishing. http://www.saludinfantil.org.pdf

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433. https://doi.org/10.1037/amp0000298

Sinyard, R. D., Rentas, C. M., Gunn, E. G., Etheridge, J. C., Robertson, J. M., Gleason, A., Riley, M. S., Yule, S., & Smink, D. S. (2022). Managing a team in the operating room: The science of teamwork and non-technical skills for surgeons. Current Problems in Surgery, 59(7), 101172. https://doi.org/10.1016/j.cpsurg.2022.101172

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