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Policy Proposal

Learner’s Name

Capella University

NHS6004: Health Care Law and Policy

Instructor Name

January 1, 2021

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Policy Proposal

Despite being recognized as one of the region’s top choices for health care, Mercy

Medical Center has areas for opportunity. The most pressing of these has been the management

of medication errors. Medication errors are associated with risks such as increase in health care

costs, reduced efficiency, and poor treatment outcomes. This paper explains the need for a

change in policy and practice guidelines to meet the recommended benchmarks in medication

errors. The proposed changes in policy and practice guidelines, the impact of environmental

factors on the implementation of the practice guidelines, and the need for involving key

stakeholders to make the implementation successful.

Need for Policy and Practice Guidelines

Medication errors in the center’s medical and surgery unit have seen a 50% increase from

4 in 2015 to 8 in 2016. Nute suggests that medication errors may result in longer hospital stays

and higher rates of mortality and morbidity (as cited in Kavanagh, 2017). According to Rafter et

al., these errors may result in an increase in the cost of health care (as cited in Kavanagh, 2017).

Incidents resulting from medication errors require additional resources and more care

interventions, which leads to a decrease in the efficiency of health care services provided.

Considering the expense medication errors can entail for patients and health care practitioners,

there is a need for an organizational policy to address the shortfall in the reduction of medication

errors.

Medication Error Analysis

According to Zhan et al., because of the fear of repercussions such as disciplinary action

being taken, a large number of medication errors go unreported (as cited in Weant et al., 2014).

However, learning from these errors will help reduce their recurrence and improve care

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interventions. Every reported error is an opportunity for the development of a countermeasure

and will help avoid or reduce the impact of the same error in the future (Weant et al., 2014).

A health care system that exposes patients to medical errors needs to be critically

evaluated. Failure mode and effects analysis is a technique that can be used to analyze incidents

related to medication errors. Under this method of analysis, the medical center can commission

the formation of a multidisciplinary committee that will review processes susceptible to errors.

Based on the inadequacies observed, the committee can classify the medication errors according

to the priority in which they need to be addressed (Weant et al., 2014). As part of the analysis,

the committee will review the steps in the process, the things that could go wrong, the reasons

behind them, and the possible repercussions (Institute for Healthcare Improvement, n.d.). Based

on these factors, the committee can recommend actions to reduce the possible errors in the

process. The analysis will end with an evaluation of the prescribed actions for improvement

(Centers for Medicare and Medicaid Services, n.d.).

Automated Dispensing Cabinets

An automated dispensing cabinet is a computerized medication distribution system that is

installed in patient care units. It stores, dispenses, and electronically tracks drugs at the point of

care. Using these cabinets can help the medical center profile patients, reduce the time taken to

retrieve medication, and track inventory on a real-time basis (Weant at al., 2014). These cabinets

usually contain high-alert and controlled medications and can only be accessed using an ID and a

password. With the use of these cabinets, nurses will not have to walk long distances to collect

the required medication (Rochais et al., 2014).

Policy and Practice Guidelines for Managing Medication Errors

Policy Statement

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Medication errors pose a risk to patient safety and public health. This policy is a guide for

health care practitioners to enable them to take appropriate action in the event of a medication

error. The practice guidelines and recommendations will provide a framework to improve the

practice of the two proposed evidence-based strategies.

Scope

The policy applies to nursing staff, medical staff, emergency and allied care practitioners,

and staff employed at the pharmacy. All concerned individuals are responsible for the

prescription, dispensation, and administration of medicines.

Practice Guidelines

The multidisciplinary local patient safety committee (which includes professionals from

various disciplines such as nursing, pharmacy, and medicine) should regularly go over the

existing action plan to improve health care outcomes. The committee must assess apprehensions

and go over events that possibly endanger patient safety. It should also analyze trends in

medication errors as well as address systemic weaknesses (Polnariev, 2016). According to

Schlesselman, around half of all possible medication error events can be averted by patient

education. Pharmacists can counsel patients when they are visited for consultations. Training

sessions on counseling patients will aid the effectiveness of pharmacists’ consultations. These

training sessions should include an emphasis on asking open-ended questions to patients (as cited

in Polnariev, 2016) such as the following three prime questions: (1.) What did the physician tell

you the medication is for?, (2.) How did the physician tell you to take the medication?, and (3.)

What did the physician tell you to expect? The sessions should also emphasize listening to

patients patiently, learning to identify inaccuracies in their responses, and demonstrating to them

the use of medication devices (Lauster & Srivastava, 2013).

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Before the administration of any medication, a review of medication orders by a

pharmacist will ensure the safety of the hospital’s medication system. Barcode verification

should be put in place for the stocking of medications. Limited amounts of medication should be

placed in the cabinets, and the cabinets should be refilled frequently (Hyland et al., 2007). For

the nursing staff, barcode verification will validate the 7 rights of medication administration:

right patient, right drug, right dose, right time, right route, right reason, and right documentation.

These 7 rights will be verified while administering medication. A nurse will scan the barcode on

his or her identification badge, on the patient’s wristband, and on the medication. Software will

analyze the real-time data, and based on the database, it will generate approvals or warnings

(Shah et al., 2016).

When choosing and placing medications within automated dispensing cabinets, products

that look alike should not be placed inside the same multiple-product drawer. Medications should

be retrieved from the cabinet for one patient at a time and administered without delay. Training

sessions about the right practices related to the use of automated dispensing cabinets should be

organized for the staff. The staff must be educated about unsafe practices that can affect patient

outcomes negatively such as retrieving medications in advance and retrieving medications for

multiple patients. They must also be educated about the need to report problems such as similar

drug name pairs being displayed on the drug selection screens on the cabinets (Hyland et al.,

2007).

Effects of Environmental Factors

The implementation of both practice guidelines, medical error analysis and the use of

automatic dispensing cabinets, can be affected by environmental factors. The efficacy of

medication error analysis can be affected if error incidents are underreported or if errors are

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incorrectly documented. Barach and Small state that error incidents are usually reported verbally

despite how frequently they occur. This can lead to an underreporting of errors (as cited in Elden

& Ismail, 2016). Moreover, verbally communicating errors can lead to errors in documenting

data. According to Claudia et al., the scope for the improvement of patient safety will be limited

if errors are discussed verbally (as cited in Elden & Ismail, 2016).

In the use of automated dispensing cabinets, incorrect restocking is one of the problems

that can arise, which can result in treatment delays. Apart from this, inaccurate documentation of

doses retrieved from the automated cabinets can also affect timely treatment. This can lead to

incorrect administration of medication (Hamilton-Griffin, 2016). Additionally, when care

providers such as nurses are affected by heavy workloads and are preoccupied with various tasks

at once, they are likely to get interrupted or distracted while collecting and administering

medication from the cabinets. To ensure that these issues do not arise, the pharmacy can be asked

to share an updated list of the stock on a daily basis. A staff member or nurse can be tasked to

cross-check the cabinet stock against the list provided by the pharmacy. Further, reassessing the

stock from time to time and using barcode technology for restocking medications can also reduce

the possibility of such errors occurring (Pennsylvania Patient Safety Authority, n.d.).

Clinicians need to be provided with continuous education on new drugs, procedures, and

policies so that the proposed practice guidelines are effectively implemented. Apart from that,

creating simulation environments will also instill confidence in care providers about their

competency in medication administration. It is necessary to create a culture of safety within the

organization, which will allow care providers to freely report errors without the fear of negative

consequences and coercion.

Stakeholder Involvement in Implementing Proposed Strategies

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Assistance can be sought from key administrative personnel such as the chief executive

officer, director of nursing, or chief operating officer. These individuals can form a quality

committee where they can share their expertise and monitor the effective implementation of the

proposed strategies. By establishing role accountability and articulating the organization’s

quality improvement norms from time to time, the key administrative personnel can reinforce a

culture of safety among the health care staff (Parand et al., 2014). The main nursing staff should

also be involved because they deal with a lot of medication administration problems firsthand.

They can help in the identification of the inadequacies that cause medication errors (Blake,

2017). While receiving prescriptions at the pharmacy, pharmacists can check for discrepancies

and contact the prescribers for any changes in orders before the prescriptions are filled out (The

Health Foundation, 2012).

The involvement of the hospital administration and the care providers will lead to

transparency in the implementation of the strategies. It will bring in multidisciplinary expertise,

create room for debate and discussion, and ensure that the parties involved have a say in

decisions concerning these strategies. Therefore, a partnership between the hospital

administration and the care providers will ensure that the proposed strategies are implemented

effectively.

Conclusion

Incidents resulting from medication errors can reduce a health care organization’s

efficiency. However, the implementation of medication error analysis and the use of automated

dispensing cabinets can substantially reduce the chances of such errors occurring. Above all, the

most important thing for the proposed policy to be effective is the creation of a culture of safety

and quality improvement at Mercy Medical Center.

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