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).
Causes of dispensing errors can be traced by root-cause analysis or by inquiring with practicing pharmacists by means of a survey. Root-cause analysis comes closer to reality, because a survey measures on the perceptions and opinions of pharmacists. An example of the former type was a study in a UK hospital in which the researchers used semi structured interviews of pharmacy staff about self-reported dispensing errors (Anacleto, T.A., Perini, Rosa, Cesar, 2007)
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,
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.
She dispensed a prescription dose ten times stronger than what the prescription was wrote for. As a consequence, the patient, who the pharmacist gave this medicine to, suffered a stroke. I think that lack of knowledge of any drug will always bring a situation in which the patient will be the one who suffers the consequences. Chapter VIII explains different strategies to implement a safe way to avoiding medication errors and a safe administration such as assessment, planning, implementation, and evaluation. For example, a healthcare worker needs to find out of any allergies the patient might had experience with any medication and the doctor is not aware of.
Reckoning Medication Errors lays out a blueprint for change in medicinal prosperity. Unmistakably providers have various
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 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
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 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
The purpose of this project is to decrease potential medication errors in the facility. This will be done by following some strategies:
The administration of medication can be associated with a significant risk with it is recognized as a central feature of the nursing role. It should continue in order to avoid a possible medical malpractice continuous care. Nursing staff have a unique role usually given to patients to manage their medication and responsibilities, then they can report these identified medication errors. Some of the most distinguishable events can be related to errors in professional practice, prescribing, dispensing, distribution, and education or monitoring. Since medication errors can arise at any state of the administration process, it is essential for nursing staff to be attentive of the most commonly encountered errors. For the most part, the common of the perceptible aspects related with medication errors are due to minimal awareness about hospital policies, inappropriate implementation or latent conditions (Farinde, n.d).
The use of information technology can reduce errors in different ways, harmful events and medication errors may be prevented before they can occur, the time needed to resolve the cause of adverse measures can be decreased, thus avoiding reoccurrence; and (3) trends can be tracked and pertinent feedback about medication errors and adverse drug events then can be
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