Case Study: Statistical Thinking in Health Care
Samantha Norman
Dr. Zohre Ardalani
MAT510: Business Statistics
Strayer University
February 1, 2016
A major Health Management Organization (HMO), has received numerous complaints and even has been involved in a few lawsuits over inaccurate prescriptions. Juan de Pacotilla , the manager for this HMO Pharmacy, has even hired a statistical consultant to analyze the data on inaccurate prescriptions, but is very disappointed with his performance. Juan was about to be fired from his position, and has asked Ben Davis, his assistant, to help in solving the issues relating to inaccurate prescriptions. A dispensing error is a discrepancy between a prescription and the medicine
…show more content…
Dispensing the wrong information on the label, incorrect drug name, incorrect instructions, and the list goes on. By developing a process map for the prescription process for the HMO pharmacy, in which I will specify the key problems that the HMO’s pharmacy may be experiencing. Also, I will use the the supplier, input, process steps, output and customer (SIPOC) model to analyze the HMO pharmacy’s business process. Using this model it can be assumed that the HMO pharmacy can experience mistakes from all levels of the business process (Hoerl & Snee, 2012).
5-)Pharmacy assistant gives (incorrect) medication to patient
1)Patient goes to doctor with their issue/sickness
9)Patient receives (wrong) medication-they get sick
6)Pharmacist gives incorrect medication to pharmacy assistant
2)Physician writes the prescription
3)Prescription deliver to pharmacy
7)Pharmacist reads and dispenses prescription
4)Pharmacy assistant misreads prescription (barley legible)
8)Pharmacy assistant gives prescription to pharmacist
Several mistakes can be encountered from the time the patient drops off the prescription to the time it’s filled and the patient is given the wrong medication. Based on my process map, these problems can be a result from ordering, transcribing,
However, there are issues with this system as well because the computer is only as smart as we allow it to be. If pharmacy puts in the computer the wrong medication or dose, or information is incorrect, the computer will still allow you to administer. It goes back to communication, knowing your patient and how important it is to still ask questions and have conversation with your patient about the medication you are about to give them. Read their history and physical to get a better idea of everything going on with your patient so we can continue to provide safe quality care.
The common causes for these errors are poor communication, ambiguities in product names, directions to be used, medical abbreviations or writing, poor procedures or techniques, or patient misuse due to to poor understanding of the directions of the medications.
Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.
When it comes to medication errors several things may occur such as adverse drug event, unexpected deterioration, and even death in severe cases. AHRQ (2015) states, “an adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits 100,000 hospitalizations each year.” There are many ways that errors may occur such as dispensary errors, prescription errors
The rules and regulations surrounding dispensing errors in the UK are governed by the Medicines Act of 1968 ‘the Act’, and the Health Act 1999, which legislates the General Pharmaceutical Council (GPhC) through the Pharmacy Order 2010. The Act is an Act of Parliament which governs the control, manufacture and supply of medicines in the UK. It was introduced to help control the use of medicinal compounds and to increase patient safety, although much of it has been modernized and repealed. It also gives power to the courts to charge any dispensing mistakes as a criminal offence.
In Australian hospitals medication administration errors make up 9% or 1 in10 of all medication administrations. These errors include wrong doses, wrong intravenous infusion rates and errors made by prescribing doctors. Errors on discharge of patients were increasingly higher with up to 2 errors per patient related to doctors transcribing discharge medications (Roughead, Semple, & Rosenfeld, 2016).
According to the Food and Drug Administration (FDA 2009), the wrong route of administrating medication accounts for 1.3 million injuries each year. An article published in September issue of the Journal of Patient Safety estimates there are between 210,000 and 400,000 deaths per year associated with medical errors. This makes medical errors the third leading cause of deaths in the United States, behind that comes heart disease and cancer. To prevent medical errors always follow the Three Checks and most importantly the Rights of Medication Administration. The “Rights of Medication Administration” helps to ensure accuracy when administering medication to a patient. When administering medication the administer should ensure they have the Right Medication, Right Patient, Right Dosage, Right Route, Right Time, Right Route, Right Reason, and Right Documentation. Also remember the patient has the right to refuse, assess patient for pain, and always assess the patient for signs of effects.
Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of
Medication errors are focused on: terms and definitions; incidence of and harm; risk factors; avoidance; disclosure, legalities & consequences (Wittich, Burkle & Lanier, 2014). Medication errors categories have been developed by the American Society of Health-System Pharmacists (ASHP). Examples of these categories are based on prescribing, omitting drugs not administered, timing, unauthorized drug, wrong dosage, wrong preparation, expired drug, not using laboratory data to monitor toxicity (Wittich, Burkle & Lanier, 2014). Additionally, this article examines in depth common causes leading to medication errors, drug nomenclature, similar sounding drugs, unapproved abbreviations and handwriting, medical staff shortages and manufacturer medication shortages. Even though this article provides an informative overview for physicians, other allied health personnel may benefit too. This is valuable knowledge for the health care professional not just physicians in order to provide safe care for their
Medication error (ME) is a significant problem within our health care system, in terms of patient harm and cost. In July 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cited the need to reduce medication errors as a top priority. Several studies suggest that medical error is the third-leading cause of death in the United States. In fact, at least 7,000 inpatient deaths occur annually as a direct
In today’s current fast-paced and demanding field of heath care, medication administration has become complex and time-consuming task. Approximately one-third of the nurses’ time is used in medication administration. There is much potential for error because of the complexity of the medication administration process. Since nurses are the last ones to actually administer the medication to the patient therefore they become responsible for medication administration errors (MAE). Reasons for MAE may include individual factors, organizational factors or system factors. This paper will discuss the root causes analysis of MAE and strategies to prevent them.
Assuming the role of Ben Davis, write a three to four (3-4) page paper in which you apply the approach discussed in the textbook to this problem. You'll have to make some assumptions about the processes used by the HMO pharmacy. Also, please use the Internet and / or Strayer LRC to research articles on common problems or errors that pharmacies face. Your paper should address the following points:
Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error
Set-up and workflow of my pharmacy is pretty good for patient centered care. Patient does not have to wait too long for their prescriptions to be filled. Patients can call for their refills via telephone or online, which makes their life easy as they don’t have bother coming in-person for refills. Patient profile shows all medication history as well as number of refills remaining. This makes it easy for pharmacist to know whether to refill a prescription or call doctor for refill request. After confirming to fill a prescription pharmacist runs claim through insurance and print label after claim is successful. All medication is arranged alphabetically on shelves, thus it is easy and quick to retrieve. Then after technician fills medication and then pharmacist checks it. This workflow is quite smooth and quick to process. Final check is done by pharmacist, who confirms right medication for right patient as well as the NDC dispensed, amount dispensed, direction for use, and day supply. All these steps of process take place on working table in sequential order, which helps to reduce errors in filling and have effective prescription filling. Once the prescription is filled pharmacist do all paper
The data entry stage has two major problems. The first problem is drug utilization review (DUR). As showed by PSI team for the pharmacy fulfillment process, DURs arise frequently and pharmacists must waste time to intervene. CVS’s central database of customer fails to update and understand customers’ newest condition, so that the issue of DUR triggers customer’s dissatisfaction and wastes a lot of time for pharmacists. The second problem in the data entry stage is no refill allowance. Many customers may lose track of how many refills that were allowed and drop off an ineligible script