Using Case Studies as a Leadership Developmental Tool

Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”. Ensuring medication reconciliation to the patient, health providers and any new consults that are

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.

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.

* Total quality management (TQM): This model is concerned with the performance of all processes in an organisation, and the products and services that are the outcomes of those processes. It seeks continuous improvement and will involve everyone in the quest for quality.

The Joint Commission is a not-for –profit organization. It’s a private nongovernmental program that is purposed for improving the quality of health care. The Joint Commission accredits more than 21,000 health care organizations in the United States. This document has created a standard and national patient safety goal in which health care providers must comply. A list was created do to the fact that many error has been made throughout the medical system. The Joint Commission brought forth, which is known as the do-not-use-list. This list contain many errors of words been misuse when it comes down to the medical field. When dealing with medication it’s very easy to make a mistake by a hand written prescription cause by rush handing writing

The National Patient Safety Goals were created in response to the IOM article, To Err is Human: Building Safer Health Systems. These goals were written to address patient safety and are tailored depending on the health care setting to which they are written for. They address system wide solutions rather than focusing on whom or how the error was made. Medical errors have been noted as being the 8th leading cause of death in the U.S. with the most frequent of these errors being medication related (Johnson, K., Bryant, C., Jenkins, M., Hiteshew, C., & Sobol, K. 2010). Therefore a great focus on these goals is needed across the health care continuum. The goals are updated and amended on a regular basis using evidence-based research, in response to areas with high errors in patient safety.

Safe medication practices are key to every nurse since it results to safe medication administration. When medication is not administered correctly it results to adverse drug event which refers to harm to the patient that includes mental harm, physical harm, or loss of function which is as a result of a medication error (practices, 2017). Medication errors occur when a mistake is committed by a person administering medication and in order to avoid these errors safe medication practices need to be adhered to. Some of these

It is the nurse’s and pharmacist’s job to be cautious and aware of every medication they are administering by using their critical thinking skills and applying what they know to every situation. Although it is important for these individuals to be able to advocate for their patients, it also imperative that prescribers be aware of the impact they have on their patients as their actions have a domino effect. In conclusion, it is not the responsibility of a single profession to maintain safety in medication administration. It is the responsibility of everyone involved in the patient’s care. Each person who takes steps to improve the process and promote the patient as the number one priority is doing their part in refining how the healthcare system views medication

According to Kennedy (2010), “Medication errors continue to cause significant morbidity and mortality. Thus, in turn, cost the health care system millions of dollars each year in preventable costs.”(p.1). For this reason, a service such as Medication Therapy Management, also known as (MTM), which can be described as a diverse service or services that focus on drug therapy with the objective to improve healthcare services was introduced throughout the health care systems. This is done by improving pharmaceutical safety which results in enhanced therapeutic results for individual patients, meanwhile reducing cost for both the patients and healthcare institutions. In order for MTM to be successful and to ensure that patients get more

It is evident that patient safety is one of the most important principal in place as a nurse. To insure this there are many standards that are set in place that as a registered nurse need to be met, some including, professional responsibility and accountability, having knowledge based practice, ethical practice, service to the public and self-regulation (SRNA, 2014). “These standards and foundation competencies serve as the criteria against which all registered nurses, practising in all domains of nursing practice (direct care, education, administration, and research, and the evolving domain of policy) will be measured by clients, employers, colleagues and themselves”(SRNA, 2014). Having these standards allows register nurses and the public to have a clear understanding of what needs to be met in order to insure that there is proper patient safety. However there are still many issues that contribute to unacceptable patient safety, including medication administration errors, post operative care, and patients mental health. However, “medication errors are one of the most common types of medical errors that occur in healthcare institutions” (J.Choo, 2010). A medication error, according to The National Coordinating Council for Medication Error Reporting and Prevention “is 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

The process emphasizes modifications of system when there are changes to achieve organizational goals (Begunn, Kaissi & Sweetland, 2005). For example, a leader’s approach to patient safety could be a Continuous Quality Improvement (CQI). CQI is an approach to quality management; it principle is built on the traditional quality assurance that emphasizes on an organization and it systems. It focuses on process rather than an individual; it recognizes both internal and external customers and it improve system processes.

Continuous quality improvement also known as CQI is an implementation means for advancing the excellence of value presented by associations. Continuous quality improvement appertains to encompassing a standardized way to accumulating and evaluating information or data, in pursuance of to classify contingency to progress the process of a business with the conclusion of distributing improved benefits to consumers or patrons. CQI is a guided path to superiority development that accentuates a continuing or recurrent development of enhancement and assessment.

Continuous Quality Improvement is a process to ensure programs are systematically and intentionally improving services and increasing positive outcomes for the families they serve. CQI is a cyclical, data-driven process; it is proactive, not reactive.

Throughout time, medication has always been a staple in the health care field. From simply relieving a symptom such as pain, to the complete elimination of a microbe, medication has been used for everything. At this point in time, the number of different medications is countless and is constantly increasing to keep up with the continual process of adaptation and change of microorganisms. With the copious number of drugs and the persistent increase of patients, it becomes difficult to keep everything precise and free of errors. This is exactly why there have been healthcare facility guidelines implemented in practice to greatly lower and ideally eliminate medication errors all together, because it is the responsibility of the medical team

2004). New clinical safety measures have been applied to medication safety such as the use of