Upon completing the course of Statistical thinking: Improving business performance Ben Davis remembers learns the three principles of statistical thinking. The principle that we will be using in this case, would be the first one that says, “All work occurs in a system of interconnected processes (how the business or processes works). As a pharmacist's assistant in the HMO's pharmacy, Ben must create a process approach on how improvements can be made in prescription accuracy. “Fingers are being pointed, for example: the pharmacists blame sloppy handwriting and incomplete instructions from doctors for the problem; doctors blame pharmacy assistants like me who actually do most of the computer entry of the prescriptions, claiming that …show more content…
In a similar case, “ASHP Guidelines on Preventing Medication Errors in Hospitals,” was experienced prescribing error incorrect drug or instructions for use of a drug product ordered or authorized by physician; illegible prescriptions or medication orders that lead to errors that reach the patient (1993). Another problem that might occur at the doctor’s office the doctor might misunderstands the patients concerns or symptoms and misdiagnose the patient. Sometimes accidents might occur and the patient might not get well and goes back to see the doctor and the doctor to correct their mistake. When mistake takes place there should be a monitoring and managing action plan should be put in place. An appropriate and correct statistical thinking required to apply the statistician’s finding for improving the prescription process by the pharmacist in this process is lacking and that is the root problem for the prescription issue in this process. Another problem that ties in with this problem is the doctor handwriting; the person that enters the prescription may not understand what it says. They assumes it says something totally different written and that is another reason why it is important for the verification of the prescription with the doctor. The problem is a common-cause variation as the right statistical thinking is the inherent requirement of the prescription process (Horel & Snee,
In the UK, there are more than 1 billion scripts prescribed and dispensed every year (HSCIC, 2013). There are over 12,000 pharmacies in the UK, and approximately 1.6 million people visit a pharmacy every day (HSCIC, 2013). It is therefore natural to assume that between these 1 billion prescriptions, an error or mistake will be made. Current studies suggest that of all the dispensed medicines, there are approximately 0.01-3.32% errors made in community pharmacy and 0.02-2.7% in hospital pharmacy (James et all, 2009).
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.
This is a journal study to investigate the perceptions and opinions of the professional community pharmacy staff about the causes of dispensing errors and strategies to prevent these errors. A survey was completed by pharmacists and pharmacy technicians in 49 community pharmacies and the response rate was 90.9% (Lopes, Joaquim, Matos & Pires, 2015). Handwritten prescriptions were the most single cause of medication errors 51.5% and drugs with similar packages 45.6% (Lopes et al., 2015). Checking prescriptions and confirmation of drugs through barcodes was 97% which were the most agreed prevention methods (Lopes et al., 2015). This article would not only be useful to pharmacy personnel but to other health practitioners or students performing research. In addition, a study similar to this could serve as an example (initiative) that may benefit management. Such initiative would be implemented to help improve medication
This integrative review sought to identify and understand the impact of information technology in on medication errors. The review of 14 papers shows that the implementation of medication management systems, which include CPOE, BCMA and automated dispensing machines has successfully reduced medication errors and adverse medication events significantly, particularly the two most susceptible stages of prescription and administration of drugs (Armada et al., 2014).
The issues addressed are Findings 1 and 3: Finding 1 is patient medication errors are up and there is a perception of shady hiring practices and playing favorites. All employees are responsible for compliance. Policies and professional standards exist for the medical profession. The challenges will be reintroducing employees to Federal and state law that govern the profession. For hiring practices and playing favorites the challenges faced are the lack of compliance reporting structure or training for understanding compliance. There is a perception that work rules are not being enforced. Finding 3 is high job turnover and low employee morale. The challenges faced will be building communication strategies, building confidence in leadership,
The hospital should consider implementing “electronic prescribing through “computerized provider order entry systems” ( Radley, Wasserman, Olsho, Shoemaker, Spranca, & Bradshaw, 2013, p. 470). This system is an effective way to reduce patient harm associated with medication errors (Radley et al, 2013). In fact, The Institute of Medicine (IOM) recommends the use of the “electronic prescribing (e-prescribing) through a computerized provider order entry (CPOE) system” as an effective method to address such issues (Radley et al, 2013, p. 470). Medication errors are often a result of misinterpreted handwriting or poor handwriting (Radley et al., 2013). The use of electronic prescribing reduces medication errors associated with those reasons (Radley et al., 2013, p. 470). Studies prove CPOE reduces medical errors (Radley et al, 2013, p. 473). However, there were some mediation errors associated with electronic prescribing as the study also pointed out. The study found that users or
One of the most complex challenges that healthcare facilities face, are the high occurrences of medication errors. Due to increased incidences of medication errors, it has become a major priority for healthcare systems to find preventions that could simply decrease medical errors. With evidence provided from different research healthcare systems are moving more towards using computerized information technology for simple automated notes, too bed-side bar code medication administration, electronic medication reconciliation and physician order entry’s as strategies to decrease medication errors (Agrawal, A. 2009).
The words medication error elicit fear in every nurse. According to Stefanacci and Riddle (2016), preventable medication errors are responsible for third reason of death apart from heart disease and cancer in the United States. As a nurse, it is important to obtain skills and knowledge to prevent them as these errors could result in extended hospitalisation of patients, simultaneously a burden of health care cost. These errors could be reduced by identifying the problems which lead to medication errors and following certain protocols in a coordinated environment.
There are now computers in every room, in almost every healthcare facility. Nurses now chart most of their medication administrations in the room and can focus on one patient at a time. A nurse must scan the patient’s band or some identifier and scan the meds before giving the medication to the patient. The computer program will tell the nurse if he or she made a mistake with the time of medication, wrong dosage, wrong medication, and/or wrong patient. In a hospital in England, there was a declined in medication errors from 8.6 percent to 4.4 percent when a new computer system was implemented. Prescription errors were also reduced from 3.8 percent to 2 percent. The new system was computerized order entry, automated dispensing, and had electronic medication administration records. Technology has greatly reduced the percent of medical errors, but not all of them, but by studying different systems and modifying systems hopefully medication errors will be a thing of the past (Hughs & Blegen,
Understanding medication error means understanding the impact an error can have on the medical community and patient care. When a medication error occurs, stress is often placed on the medical facility, as well as the effected patient and family. Regarding a medication error one can assess that an error has in the medication process- rather it be missing actions or wrong actions, the medical facility must undergo an investigation (Lisby, 2004). During the investigation, depending on the severity of the error, the person or people who are involved with the
There are many rules and precautions taken to ensure that medication errors do not happen. In nursing school students in the RNs and BSN program are both taught ways to not make medication errors. A study done by Margret Harris, Laura Pittiglio, Sarah Newton, and Gary Moore was done to see if simulation can be used to improve medication administration to reduce medical errors.
The health information technology (HIT) topic selected is medication errors. In his March 17, 2017 article titled, “Poorly Implemented IT systems lead to medication errors” author Evan Sweeny discusses a the findings of Pennsylvania Safety Advisory which found that information technology (IT) systems implemented to prevent medication errors, may in fact contribute their occurrence. This paper will examine how HIT can both prevent and contribute to medication errors. The following elements are included, introduction, the rationale for selection, positive and negative impact of health information technology on medication errors, how informatics skill was relevant in assignment development, and
The purpose of this project is to decrease potential medication errors in the facility. This will be done by following some strategies:
This article talks about human errors in dispensing drugs. Adverse drug reactions have reportedly claimed more than 100,000 lives in America. Pharmacy mistakes may have contributed to the deaths as a result. Studies uncovered that these human errors were mainly caused by distractions and interruptions. Other contributing factors include long working hours, heavy workloads, complicated procedures, misinterpretation and work stress. Pharmacists were generally asked to handle a huge amount of tasks within a short span of time. The tasks include reviewing patient’s profile, verifying with patient for any drug allergies, dispensing drugs and counseling for new drugs. Studies have also shown that over the years, the demands for prescriptive drugs
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