The Quality Chasm

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.

The Quality Chasm report underscores the lack of quality healthcare, cost concerns, poor use of information technology, absence of progress in restructuring the health care system, and the underutilization of resources (Stevens, et al., 2006). The quality issue that this writer has chosen to address is the poor use of information technology. According to the Quality Chasm Report, health science and technology have advanced at a very rapid pace, but due to poor use of information technology, the healthcare delivery system has not maintained delivery of high-quality healthcare services. Research results are not translated into practice, and practice lags behind knowledge (Stevens, et al.,

Today’s healthcare system requires that healthcare professionals across the globe change their focus towards evidence-based practice to meet the needs of the complex clinical setting and constantly strive to improve patient care and outcomes. The United States Institute of Medicine (IOM) has created five core competencies to be utilized by all health care providers in order to enhance patient outcomes (Inter-professional Education Collaborative Expert Panel, 2011). The competencies are employing evidence-based practice, working in interdisciplinary teams, applying quality improvement, utilizing informatics, and providing patient-centered care (Institute of Medicine, 2010).

The Institute of Medicine (IOM) recommends five core competencies that all clinicians should possess in order to satisfy the needs of the 21st century health system. The report says that doctors, nurses, pharmacists and other health professionals are not being adequately prepared to provide the highest quality and safest medical care possible, and there is insufficient assessment of their ongoing proficiency. Educators and accreditation, as well as licensing and certification organizations should ensure that students and working professionals develop and maintain proficiency in these five core areas (U.S. Department of Health and Human Services, 2014):

One of these reports is “Crossing the quality chasm: A new health system for the 21st century” by the Institute of Medicine (IOM, 2001). After more than a decade being published, this report continues providing useful and relevant information. The report explains six dimensions of quality that need to be achieved by the healthcare system to improve quality, the six aims are: Safety, Effectiveness, Efficiency, Timeliness, Patient centered care, and Equitability. (Joshi, 2015, pg 6)

Medication administration is a multi-step process that is handled by multiple healthcare professionals. It begins with the prescription that is transcribed mostly by the physician, then dispensed by the pharmacist, and ends with the administration of the medication by the nurse. Throughout this multi-step process, medication errors can occur at any stage of the medication administration process. As expressed by L. Cloete in “Reducing medication errors in nursing practice,” “One third of the errors that harm patients occur during the nurse administration phase: administering medication to patients is therefore a high-risk activity.” Because the nurse is responsible for administering medication to the patient, he/she is considered and viewed as the most accountable in regards to the patient’s safety. Medication errors are one of the most common medical errors that can result in an adverse event that may pose a serious threat to the patient’s safety and well-being. In the article, “An inside look into the factors contributing to medication errors in the clinical nursing practice,” Savvato and Efstratios defined and characterized medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication;

The Causes of Medication Errors in Nursing Medication errors are among the most common type of medical error, and it is widely known that the consequences can be very significant for the patient. Medication errors also affect healthcare individuals leading to personal and professional embarrassment and emotional trauma of involvement in the adverse outcomes (Pezzolesi, Ghaleb, Kostrzewski, & Dhillon, 2013). The entire goal of nursing is to maintain the safety of every client, although it is no easy task. Medical management is one of the most labor intensive, and possibly one of the most risk-laden duties performed in the provision of patient care (Leufer & Cleary-Holdforth, 2013). The purpose of this paper is to determine and discuss the

About1.5 million people are harmed yearly in the U.S. because of medication errors, The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines the meaning of medication error, they define it as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer…”. (Stoppler, 2015) It is a serious topic in the nursing field that should be addressed and prevented.

The utilization of prescription drug has increased in recent times. The availability of these medications has resulted in the treatment of numerous infections and ailments. These drugs alleviate chronic pain, depression and anxiety, sleep apnea, and much more. For an efficient health system, the main goal is to provide quality health care to all patients. However, over the years, there have been many legal and health controversies over drugs and the effects that they have on the body. The process of prescription drug starts from a lab and ultimately sojourns with the end-user. The drugs undergo testing and are often developed to treat a specific disease before being reviewed by the Food and Drug Administration (FDA).

Medication errors occur more often than they should. It is recorded that medication errors occur in children every eight minutes or in every 25 out of 1900 children. Adults older than age of 65 are seven times at a greater risk of being victim of medication errors than those adults under the of age 65. What is a medication error? A medication error is a event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the healthcare professional, patient, or a consumer. The patient has to actually receive the drug in order for it to be considered a medication error. Detrimental patient outcomes are associated with medication errors. A few of the many harmful effects include medication overdose, stroke, heart attack, organ damage, harm to fetus, paralysis, and death. The numbers of occurring medication errors are staggering but they can be prevented. There a precautions to take in order to safely administer and prevent medication errors, which requires following the “six rights of medication administration”. These six rights are as followed, right patient, right drug, right dose, right route, right time & date, and the right documentation.

Safety is what we all live for and one important thing that keeps us safe are drug treatments. These medications treatments can also be fatal if it is not given the right way. These medications are usually prescript by our physician or any legal specialist. “Five of the top 10 patient safety concerns have ties to some part of the medication process” (Patient Safety Monitor Journal, 2015, P.1).Medication errors can occur during prescription, dispensing and administer.

All drugs have been created to help people assist with their body’s needs, control symptoms of a diagnosis, and improve the quality of life. Unfortunately, all drugs come with adverse events that cannot be demolished. Gratefully, the majority of adverse events have been discovered and there are ways to help eliminate some of these. All medical professionals educate themselves with adverse events, in an attempt to help our patients.

Approximately 440,000 people die every year from preventable medication errors. This is is the third leading cause of death in the United States. Many of these errors could be avoided if Medical facilities would use standard precautions when administering medications. Health care workers should be better educated in patient care and preventable medical errors, this extra knowledge could save millions of lives and save millions of dollars. To keep these medication errors from occurring, it is important that all medical staff keep increasing their knowledge about medication errors and patient care. This will help decrease the death tolls in all Medical facilities.

There are several risks associated with medication use but especially with polypharmacy, such as adverse effects, medicine-medicine and medicine-disease interactions, decreasing adherence to medicine therapy or errors in the actual use of the medicines (Walckiers, Van der Heyden & Tafforeau,

In modern healthcare, pharmaceutical medicines constitute an integral component in self-care. The public is consuming an increasing number of over the counter and prescribed medication. The exclusion of immediate guidance from a healthcare professional means that medication use is becoming more the responsibility of the patient. The ability to communicate accurate instructions and warnings is becoming more critical for safe and proper consumption.