There are 2 parts to this summative assessment. Complete Part 1 this week and submit it with Part 2 in
Week 4.
In this assessment, you will work through the planning and implementation stages of the project. This
will require you to determine goals and resources needed and to select an evidence-based practice
(EBP) model.
Part 1 – Literature Review
Research best practices to identify an effective intervention for your selected problem. Your goal is to
gather evidence from scholarly literature to support the most effective intervention strategy.
The performance appraisal tools in this week’s learning activities will help you determine appropriate
scholarly sources of evidence to cite.
Locate at least 3 original research articles that support your proposed solution to your selected problem.
The articles must be peer-reviewed, published within the past 5 years, and statistically significant.
To begin, write a 350-word summary of each article in which you:
Identify current guidelines or best practices relating to your proposed solution, or if there are protocols,
the current standard of care.
Define your proposed intervention(s) to address the problem.
Explain how the intervention will result in a solution to the problem
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Medication Errors
Keyona Thompson
NSG/498
Julie Dunlop
February 28, 2022
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Medication Errors
Quality improvement is essential to evidence-based nursing practice. Nursing leaders
have a responsibility beyond providing and supervising daily care to patients. This responsibility
is the identification of gaps in practice and opportunities to improve the quality of care and
implementing care interventions to close those gaps and improve quality. There are numerous
ways of improving care quality and one of them is identifying areas that are underperforming
and providing evidence-based solutions to be implemented to meet the performance
expectations. One such area identified in the healthcare organization is the rates of medication
errors by nurses. Medication errors may cause harm and reducing them enhances the quality and
safety of healthcare at the healthcare setting. This paper details medication error problems in
medical/surgical (med/surg) settings and proposes a solution to implement barcode medication
administration to reduce error rates.
Defining the Problem: Medication Errors
Medication errors are a serious healthcare problem affecting many patients and many
healthcare organizations. A medication error is any preventable event that may lead, or leads to
inappropriate medication use and harm due to medication use in patients. Errors occur in
different levels of the care process and may occur as early as the physician order or as late as the
administration of the medications. In general, medical errors account to more than 250,000
deaths in the US every year and are among the leading causes of death (Anderson &
Abrahamson, 2017). This is a serious healthcare problem causing a lot of harm to patients and
resulting in preventable deaths. Other than deaths, medication errors may also cause extended
hospital stay, increased cost of treatment, and injury to patients, lowering the quality and safety
of healthcare in the nation.
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The setting where the problem occurs is a med/surg setting of a primary healthcare
facility. The med/surg unit is an in-patient ward where general medical patients and perioperative
patients are admitted during in-patient treatment. Medication errors occurring in this setting are
deemed preventable because they occur under the watch of nurses and other medical personnel
such as providers. Nurses are responsible for administering medications as ordered by the
provider and hence in the unit, they can appropriately reduce the rates of errors through nursing
interventions. The healthcare organization faces a serious medication error problem which can be
addressed through nursing interventions.
Baseline data at the facility showed that medication errors have increased in the last one
year, indicating an undesirable trend. The med/surg unit has experienced the highest increase in
medication errors hence the focus of the proposed solution is this unit. In the past 12 months,
error rates in the healthcare organization have increased by 8% and by 13% in the med/surg unit.
This general increase in error rates has been attributed to high workload for nurses and most of
the errors have occurred at the drug administration level. The errors are attributed to the five
‘rights’ of drug administration: right drug, right dose, right patient, right route, and right time
(Hanson & Haddad, 2021). Any error that occurs due to one of the rights highlighted above can
be addressed by nurses who administer medications. The organization’s poor performance
regarding medication errors requires interventions to improve nursing safety.
The main goal of implementing a new intervention will be to improve the safety of
medication administration and reduce the rates of medication errors. The proposal is based on the
idea of continuous quality whereby nurses should always strive to identify areas of performance
improvement and use credible evidence to fill gaps (Hill et al., 2020). Based on that ideal, the
healthcare organization will reduce the rates of medication administration errors and improve
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patient safety outcomes. It is also anticipated that patients’ satisfaction will be improved with the
reduction of medication errors. This nursing project proposal, therefore, aims to reduce the rates
of medication errors, increase patient safety, and improve satisfaction.
Proposal to Address Medication Errors
Various solutions are available for medication error reduction and the most appropriate
for the setting is barcode medication administration (BCMA) to reduce medication
administration error rates. BCMA is a technology that can be used to assist nurses in scanning
patients’ identity and medications before administration to reduce the risk of errors. The BCMA
is a barcode-operated scanner that is linked to the patients’ records in the electronic healthcare
records (EHR) system and by scanning tags on the medications and the patient, all information
including identity, timing, and dosage can be accessed (Berdot et al., 2019). The technology
essentially reduces the cognitive load of nurses when administering medications. Nurses do not
have to remember specific patient details when they have a portable and accessible technology.
BCMA implementation will be through four main phases. The first phase is requirements
assessment whereby the healthcare organization’s equipment and technology capabilities are
assessed to determine the feasibility and needs for effective BCMA implementation. The second
phase is vendor selection and installation. An important aspect to consider in this phase is
interoperability of systems (Berdot et al., 2019). The new technology should be interoperable
with the existing EHR and other technologies such as computerized physician order entry
(CPOE) system. The third phase is user training and this will be training nurses on how to use
the BCMA technology. The nurse leader can collaborate with nursing informaticist to deliver
user education and training. Lastly, roll-out will be done with clear guidelines and protocol for
the implementation of the technology.
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The new technology and medication administration protocol will be implemented in the
med/surg unit as a pilot project to determine the utility and feasibility of BCMA in the healthcare
organization. This unit has had the most medication administration errors and the highest
increase in the last one year. Every nurse working in the unit will be expected to follow BCMA
protocol set in the unit whereby medication administration will be conducted with this
technology. Effective implementation will be indicated by consistent BCMA use in the unit. The
effectiveness of the technology will be assessed by the rates of medication errors compared
before and after the intervention. One-year rates before and after the intervention will be
compared to determine whether there is a correlation between BCMA and medication error rates.
Ethical, Legal, and Regulatory Issues
Medication errors present an ethical issue regarding the safety of patients. Nurses have a
professional responsibility to ensure the best level of care and safety for their patients within the
limits of their healthcare organization. They also have an ethical responsibility to provide safe
care and minimize human suffering due to illness. Therefore, reducing medication errors is an
ethical and professional issue. Compassionate care is needed to reduce the rates of errors and
ensure patient safety.
Moreover, errors could lead to legal issues in the healthcare organization. Errors that
result in significant injury and adverse events could be the subject of litigation. Patients who
become victims of negligent care resulting in medication errors can sue the healthcare
organization and individuals involved in the error (Mutair et al., 2021). Nurses should strive to
avoid such litigation issues by ensuring due diligence to reduce the risk of errors. Therefore,
using BCMA for medication administration and to reduce error rates can help avoid litigation
problems and the negative consequences that may affect the nurse and the organization at large.
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The introduction of new technology in healthcare also presents regulatory requirements,
especially compliance with the Healthcare Insurance Portability and Accountability Act
(HIPAA). The Privacy and Security Rules of HIPAA require that organizations put in place
mechanisms to ensure patient information confidentiality and protect from unauthorized access
(Mbonihankuye et al., 2019). The healthcare organization needs to take proactive steps to ensure
that the BCMA scanners have secure access to the EHR and also train users to reduce the risk of
breaches and unethical information handling. Solving medication error issues includes ensuring
patient information security and privacy when using BCMA.
Importance of Addressing Medication Errors
The problem of medication errors was selected for this proposal mainly because it is an
indicator of the quality of care delivered to patients. Care quality is a complex concept and
ensuring patient safety is one of the quality indicators. The nurse leader has a responsibility to
ensure high quality healthcare delivery by nurses and this is only possible if interventions to
minimize patient harm are implemented and practice maintained. Therefore, it is important to
address medication error rates in order to enhance patient safety and improve care quality.
Lastly, medication errors are a source of patient harm and they determine patient
satisfaction which affects the bottom line of the healthcare organization. Nurse leaders have a
responsibility to their employers to maintain sustainability of healthcare services and facilitate
strategic goals. High error rates may reduce patient satisfaction which leads to loss of clients in
by the healthcare organization. Losing clients in healthcare, as in other businesses, leads to a
negative impact on income. Therefore, addressing medication errors and events that arise from
them can help reduce financial risks in the healthcare organization. Medication errors affect the
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quality of healthcare and patient experiences, affecting health outcomes and organization’s
financial performance.
Conclusion
The proposed intervention will reduce rates of medication errors in the med/surg unit of a
hospital by implementing BCMA. The healthcare organization has experienced an increase in
rates of errors in the last year and this increase has mostly affected the med/surg unit. The nurse
leader proposes implementation of BCMA to assist in medication administration and
consequently reduce error rates. Nurses will use barcode scanners to verify patient and drug
information before administration. This issue is important because it affects care quality, patient
satisfaction, and the organization’s financial performance. Medication error reduction will
improve nursing performance and health outcomes in the hospital.
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References
Hanson, A., & Haddad, L. M. (2021). Nursing Rights of Medication Administration. StatPearls
[Internet]. https://www.ncbi.nlm.nih.gov/books/NBK560654/
Hill, J. E., Stephani, A. M., Sapple, P., & Clegg, A. J. (2020). The effectiveness of continuous
quality improvement for developing professional practice and improving health care
outcomes: A systematic review. Implementation Science, 15(1), 1-14.
https://doi.org/10.1186/s13012-020-0975-2
Berdot, S., Boussadi, A., Vilfaillot, A., Depoisson, M., Guihaire, C., Durieux, P., & Sabatier, B.
(2019). Integration of a commercial barcode-assisted medication dispensing system in a
teaching hospital. Applied Clinical Informatics, 10(04), 615-624.
https://doi.org/10.1055/s-0039-1694749
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., & AlOmari, A. (2021). The effective strategies to avoid medication errors and improving
reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046
Mbonihankuye, S., Nkunzimana, A., & Ndagijimana, A. (2019). Healthcare data security
technology: HIPAA compliance. Wireless Communications and Mobile
Computing, 2019. https://doi.org/10.1155/2019/1927495
Anderson, J. G., & Abrahamson, K. (2017, January). Your health care may kill you: Medical
errors. In ITCH (pp. 13-17). https://doi.org/10.3233/978-1-61499-742-9-13

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