1: Analyze the elements of a successful quality improvement initiative. Analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. 2: Analyze factors that lead to patient safety risks. Analyze the value of resources to reduce patient safety risk or improve quality with medication administration. 3: Identify organizational interventions to promote patient safety. Identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. 4: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. Present reasons and relevant situations for resource tool kit to be used by its target audience. Communicate resource tool kit in a clear, logically structured, and professional manner that applies current APA style and formatting It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative pertaining to medication administration. For example, for an initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues. Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on safety with medication administration. Each resource listing should include the following: An APA-formatted citation of the resource with a working link. A description of the information, skills, or tools provided by the resource. A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to medication administration. A description of how nurses can use this resource and when its use may be appropriate. BASED ON THIS ESSAY: Root Cause Improvement Plan Lookalike/sound-alike drugs are medications that often have either a similar packaging able or have closely similar names. The close similarity between these drugs often leads to medication errors as it is quite plausible for practitioners to administer the wrong drug on the account of the drug sharing physical or phonological similarities to the desired drug (Shultz, 2018). As a result, look-alike and sound-alike drugs names contribute to the unintended interchange of drugs that result in adverse patient outcomes, including death. Look-alike and sound-alike (LASA) drugs account for approximately 6% of medication error events and have a prevalence range of % of all prescriptions (Bryan et al., 2017). These statistics are significant given that it is estimated that 250,000 patient deaths are associated with medical errors in the United States. The fact remains, however, that medical errors associated with LASA drugs can be prevented through the adoption of several policies founded on evidence-based practices and strategies. For effective adoption of these practices, it is imperative to first gain an understanding of the drivers behind LASA medical errors. Root-Cause Analysis of Medication Errors: Look alike/sound alike Drugs As noted earlier, LASA errors are driven by the physical and linguistic properties that contribute to incorrect substitution of one medication for another (Bryan et al., 2017). LASA errors are further compounded by similarities in dosage form, strength, and product packaging (Bryan et al, 2017). One of the primary drivers of LASA medical errors is attributed to human omissions. In organizations with inadequate staffing, it is common for the staff to commit acts of omission due to fatigue or being overwhelmed (DallOra et al., 2020). Prapanjaroensin, Patrician, and Vance (2017) report that in environments where nurses work extended shifts, it is not uncommon for the staff to report low attention spans. The reduction of inattentiveness is a by-product of fatigue and burnout associated with extended working periods and lack of sufficient rest. Kakemam et al. (2021) observed that burnout was closely related to medication errors during the COVID-19 pandemic when the global health care industry was stretched to its limits. The second contributor to medication errors, inclusive of LASA-related errors, is related to communication. It is a common occurrence for miscommunication to happen between attending physicians and attending nurses of pharmacists. These communication errors, especially when faced with emergencies, often involve the miscommunication of drug interventions. For instance, the physician may misname a drug, leading the attending nurse to believe the patient has prescribed a drug with a similar sound. In other cases, patients may inadequately communicate their medical history often stating that they were administered a drug that sounds close to the right drug. In the majority of most miscommunication leading to LASA medication errors, the communication is often oral, making it easier to counter problems occasioned by miscommunication. Another significant cause of LASA medical errors is attributable to drug manufacturers. In a bid to gain market share for new drug intervention, manufacturers have been known to use names closely related to successfully marketed drugs. As a result, some new drugs in the market often share similarities with other drugs in their packaging and names, contributing to the prevalence of LASA misidentification in clinical settings. Moreover, manufacturers also tend to use product packaging that is similar to other successful drugs in an attempt of gaining a market share. These drugs are typically aimed for over-the-counter subscriptions, where patients are likely to make LASA-related errors. These three causes of LASA-related errors can be addressed in clinical settings by reducing the occurrence of fatigue or distractions, improving communications, and discouraging manufacturers from influencing LASA occurrences. Application of Evidence-Based Strategies to Decrease Mediation Errors: Look alike/sound alike Drugs Reducing Interruptions, distractions, and fatigue. Health care organizations must strive to create environments where the staff is not subject to fatigue, burnout, interruptions, and distractions. Pertaining to interruptions and distractions, it is imperative for health care settings to be free from unnecessary commotion and to require orderly proceedings such that nurses are not interrupted or distracted when noting a patients prescription. It is also imperative to ensure that attending nurses write down a patients prescription. The same requirement should be required from attending physicians to reduce the occurrence of LASA-related medical errors. Research also suggests that practitioners should form a habit of spelling out the drug names to further reduce the occurrence of LASA medical errors. To combat the occurrence of LASA errors attributed to fatigue and burnout, health care organizations are often required by statute and regulations to have adequate staffing. The human resource department of most health care facilities, for instance, is required to ensure a health nurse-patient ratio (Qureshi et al., 2019). A healthy nurse-patient ratio also helps in the development of relationships between nurses and patients that are vital in the improvement of patient outcomes. Research shows that patients who have a significant relationship with their caregivers are more likely to experience better outcomes compared to those who lack a meaningful relationship. The data suggests that nurses who have a personal connection with their patients are less likely to occasion medication errors compared to their counterparts who do not develop meaningful relationships (Strands and Bondas, 2018). Storage Practices. Health care institutions must develop storage strategies for LASA drugs that keep drugs with similarities apart from each other. The storage strategies must ensure drugs with similar names or physical appearances are stored in different sections to avoid staff from making medication errors during prescription. From a psychological perspective, requiring different processes for accessing drugs with similarities differentiates them in the practitioners mind, making it less likely for the practitioner to commit LASA-related medication errors (Sarfati et al., 2019). Typographic distinction. Printed labeling on drug packaging can be initialized to make the labels and lettering different in the case of LASA drugs. Studies have suggested that the use of Tall Man lettering for sound-alike drugs can be an effective strategy in helping staff differentiate between them. The lettering scheme makes sound-alike drugs unique from each other, thus helping reduce the likelihood of medication errors (Bryan et al., 2017). The authors described Tall Man lettering as selective capitalization of letters in a drugs name such that they are more observable to practitioners (Bryan et al., 2017). Barcoding. Barcoding is another intervention that has supported research as an effective way of addressing LASA medication errors. The use of barcodes can help practitioners quickly differentiate between both sound-alike and look-alike drugs. The computing device attached to the barcode reader is not susceptible to the phonological or physical similarities between the drugs, and it can therefore help the user differentiate between LASA drugs. Improvement Plan The healthcare institution should implement a drug storage policy where LASA drugs are kept in different storage units. Ideally, a drug that shares physical or phonological similarities with another drug should be stored in a different cabinet from the other drugs. Nurses charged with drug prescriptions should receive prescription communication in writing and in environments less prone to distractions. Moreover, the prescribing agent should be equipped with a bar code reader to minimize the likelihood of LASA medication errors, and should also benefit from frequent shift changes to minimize the effects of fatigue in medication errors. Conclusion LASA medication errors are attributable to the human susceptibility to patterns in their environment. Both audio and physical patterns can cause practitioners to misidentify drugs during prescription leading to adverse patient outcomes. The main contributors of LASA medication errors can be categorized into human and institutional errors. Both these categories include errors caused by fatigue and those occasioned by miscommunication. It is a commonly accepted fact that fatigue often causes a reduction of attentiveness. Therefore, fatigued nurses have lower attention spans and therefore are more susceptible to committing LASA medication errors. While fatigue and burnout are typically associated with organizational staffing policies, they are also human errors as fatigued nurses have an ethical duty to withdraw their services on the basis that their diminished capacity can occasion adverse patient outcomes. Miscommunication, on the other hand, can be attributed to both distractions and misinterpretation of oral communication. It can cause LASA medical errors when a practitioner believes they heard the name of one drug while the communicating party meant another drug. Solutions for overcoming these drivers of LASA medication errors include storage policies, barcoding, and reducing distractions, fatigue, and interruption in medical settings. The solutions are largely grounded on the desire to remove the confusion occasioned by LASA drugs. References DallOra, C., Ball, J., Reinius, M., & Griffiths, P. (2020). Burnout in nursing: A theoretical review. Human resources for health, 18, 1-17. Montgomery, A. P., Azuero, A., Baernholdt, M., Loan, L. A., Miltner, R. S., Qu, H., … & Patrician, P. A. (2021). Nurse burnout predicts self-reported medication administration errors in acute care hospitals. The Journal for Healthcare Quality (JHQ), 43(1), 13-23. Prapanjaroensin, A., Patrician, P. A., & Vance, D. E. (2017). Conservation of resources theory in nurse burnout and patient safety. Journal of Advanced Nursing, 73(11), 2558-2565. Qureshi, S. M., Purdy, N., Mohani, A., & Neumann, W. P. (2019). Predicting the effect of nursepatient ratio on nurse workload and care quality using discrete event simulation. Journal of nursing management, 27(5), 971-980. Sarfati, L., Ranchon, F., Vantard, N., Schwiertz, V., Larbre, V., Parat, S., & Rioufol, C. (2019). Human?simulation?based learning to prevent medication error: A systematic review. Journal of evaluation in Clinical Practice, 25(1), 11-20. Shultz, M. D. (2018). Two decades under the influence of the rule of five and the changing properties of approved oral drugs: miniperspective. Journal of medicinal chemistry, 62(4), 1701-1714. Strands, M., & Bondas, T. (2018). The nursepatient relationship as a story of health enhancement in community care: A meta?ethnography. Journal of advanced nursing, 74(1), 11-22Show more
