NHS-FPX4000 Analyzing a Current Health Care Problem or Issue

Analyzing a Current Health Care Problem or Issue

Medical error is one of the issues affecting the health care sector across the globe. It is a critical public health concern that stands as one of the leading causes of death in the United States and the global health sector in general. A major challenge in the health system is to define the consistent factors that cause medical errors. According to Bishop, Cohen, Billings & Thomas (2015), medical error is the preventable adverse impact of care regardless of whether it is evident or harmful to the patient. Chiewchantanakit et al. (2020) notes that almost 60% of medical errors occur during the transition of care. Medical errors can be caused by communication breakdown whether verbal or written and these may arise in medical practice or in healthcare system. they can occur between a physician, nurse, or patient. Poor communication results in medical errors.  In my analysis, I intend to provide a critical perspective of the problem in the healthcare sector. In essence, I will include an analysis of the elements of the problem and frame the issue into context within the health system. I will also discuss the possible solution to medical errors, the most effective solution and the ethical implications of the selected solution, and the implementation of the requirements for this solution.

Elements of the problem

According to Grondin et al. (2021) although medical errors are unintentional, they have adverse impacts on the patients and the families. One common medical error is wrong prescription which may unintentionally cause arm to the patient. Berthe et al. (2017) posits that one of the possible causes of these errors that can be prevented is poor communication. Communication is one of the important elements in nursing that enhances patient safety and wellbeing. It is a critical skill needed in medication reconciliation at every transition point from admission to discharge. Effective communication is an important competence that helps prevent medical errors and adverse drug events.

Enhanced patient understanding and adherence is achieved through provision of both written and verbal instructions after every encounter. The administration of medication at consistent times and provision of the exact number needed for every dose also increases the adherence and reduces the errors. According to (Street et al., 2020) communication breakdown among clinicians, patients and family members also result in medical errors. Effective communication helps eliminate this issue within the health setting. patient and family involvement are encouraged in the medical care process to prevent errors. The health systems also need to be improved to provide meaningful information in a timely manner to prevent medical errors.

Analysis of the Issue

As a nurse and a case manager, it is imperative to appreciate the common causes of medical errors to be sure they are addressed and eliminated at the department of practice. one of the main issues to note as a case manager is communication problems as these rank as the most common factor. The issues can arise in medical practice between the healthcare professionals and can result in medical errors. There are also patient related issues where patient identification, inadequate patient assessment, failure to obtain consent and insufficient patient education. These, among others are some of the causes of medical errors to be aware. Continuous learning should help a nurse and case manager to identify issues over time and work on addressing them.

Medical error disclosure and patient safety improvement are inextricably intertwined, and give one of the most compelling reasons to record and disclose errors, even near misses that do no harm to the patient. According to Honavar (2019), the paradox of modern quality improvement is that the rate of mistake can only be decreased by admitting and forgiving it. Error reports may also be useful learning tools for individuals directly affected as well as the broader health-care community. Nonetheless, when it comes to reporting medical errors, especially major ones, the US health-care system has a poor track record. The Institute of Medicine (IOM; Washington, DC) (2013) estimates that over 1 million avoidable adverse events occur in the United States each year, with up to 98,000 of them resulting in death, an amount equal to one major airplane catastrophe every day (James, 2013).

Context of Medical Errors

Medical error is associated with patient safety, harm and high medical costs following readmission and adverse drug reaction. The possibility that the error will occur depends on the age of the patient, comorbidities, high-risk drugs and other patient complications. According to Manias, Kusljic & Wu (2020), the general population lives longer, and chronic illnesses are more prevalent in the younger generations. Therefore, patients are given more prescriptions to enhance their quality of life and deter morbidity. The transition of care makes patients be at high risk of medical errors from loss of information and ineffective communication.

Affected Populations

All population demographics are likely to be affected by a medical error in transition care and patient discharge with a list of medications. However, geriatric patients are most affected since they are more apt to be poly-medicated. This population experience up to 53% of reconciliation errors during a hospital stay. The results of these clinical errors are at a greater risk of being more serious in elderly, frail patients than in the younger generations.

Available Options

Medical errors during discharge may be reduced by developing an effective reconciliation process that keeps the patients safe and prevents hospital readmission. The process may involve effective communication between the healthcare workers, pharmacists, and Electronic Health Records (EHRs). According to Allison, Weigel & Holcroft (2015), enhancing communication between health professionals, patient and family members is a step to reduce medical errors. Past research shows that hospital pharmacists need to be integrated into the systemic review to stand a chance for successful transition upon discharge. Tele pharmacy also shows an effective approach to reducing medical errors, particularly in rural areas, as the pharmacists are very few. The interdisciplinary partnership proves to successfully assist the clients’ complete and accurate medication reconciliation. The process helps promote patient satisfaction and patient outcome in medical prescriptions.

Patton, Monrad, Zaidi & Abbott (2018) posits that an electronic health records system is another approach to enhance communication of the medical changes during hospitalizations. The changes made in a patient’s record from admission to medication and discharge is effectively communicated through the electronic system and accessible to all the attending physicians.

Solution

Communication-related themes fall within the theme of provider-focused communication and patient/family communication. healthcare providers are recommended to ensure the they take the patient/family questions and concerns seriously and provide meaningful information in a timely manner. The most common advice offered for patients and family are assertive and proactive especially when asking questions, reporting concerns and following up as well as getting second opinions. Patients are also recommended to speak up in discussions with clinicians. Providers should encourage their patients and family members to speak up if they believe something is wrong with their care and strive to make it easy, comfortable and safe for the patients to voice their concerns.

When the communication issue is addressed, the ethical principle of beneficence and nonmaleficence will have been applied efficiently. This principle directs the healthcare providers to do what is best for their patients and avoid any activities that may harm them. The solution to this issue will see to it that the nurse or case manager takes all the necessary steps to encourage communication in their setting and reduce the possibility of medical errors. The principle of veracity will also have been employed in the case. This principle obligates the health professionals to provide comprehensive, accurate and objective information in a way that helps the patients to understand the information. This will ensure the patient-related issues that cause the medical errors are eliminated as they will have clear knowledge and information of how they relate with the professionals and how to handle their medication.

Implementation

One of the significant parts in improving patient safety and outcome relies on the procedural approach to a more accurate medical reconciliation. However, there is an extreme aspect of the process. The disclosure of medication is important for more than the patient’s benefit. When the medical error is disclosed regularly, there is a chance that the data will be used to understand the system and give more insights on the recurring issues. According to Redmond et al. (2018), patients and their families expect the nurses and other physicians to be transparent in their communication and disclose any errors. The patients desire to be informed in case of an error and no detrimental outcome. They also want an apology and assurance that the facility will do the necessary to prevent further errors.

Research on physician disclosure of medical errors depends on the issues they opt to present and whether they apologize. This is because patients have a different definition of error. The professionals have a narrow definition of the problems, unlike the patients. Therefore, the ethical perspective implies that this topic needs to be explored to understand medical errors fully and find effective measures to prevent them.

Conclusion

Medical errors have become common and associated with adverse consequences. Medication reconciliation is presented to reduce discrepancies that may harm the patients when they are discharged. It is also a needed process in any transition of care. Developing an efficient and effective process is imperative to enhance patient safety and prevent readmission to the hospital. Nursing ethics implies a lot to be done to promote disclosure of errors to allow the teams to learn from the events and know how to prevent or mitigate them.

References

Allison, G. M., Weigel, B., & Holcroft, C. (2015). Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?. International Journal Of Health Care Quality Assurance, 28(6), 564–573. https://doi.org/10.1108/IJHCQA-12-2014-0113

Berthe, A., Fronteau, C., Le Fur, É., Morin, C., Huon, J. F., Rouiller-Furic, I., Berlioz-Thibal, M., Berrut, G., & Lepelletier, A. (2017). Medication reconciliation: a tool to prevent adverse drug events in geriatrics medicine. Geriatrics And Psychology Neuropsychiatry Of Aging, 15(1), 19–24. https://doi.org/10.1684/pnv.2016.0642

Bishop, M. A., Cohen, B. A., Billings, L. K., & Thomas, E. V. (2015). Reducing errors through discharge medication reconciliation by pharmacy services. American Journal Of Health-System Pharmacy : AJHP, 72(17 Suppl 2), S120–S126. https://doi.org/10.2146/sp150021

Chiewchantanakit, D., Meakchai, A., Pituchaturont, N., Dilokthornsakul, P., & Dhippayom, T. (2020). The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis. Research In Social & Administrative Pharmacy : RSAP, 16(7), 886–894. https://doi.org/10.1016/j.sapharm.2019.10.004

Grondin, C., Gupta, A., Houchens, N., Heidemann, L., Petrilli, C., Siler, A., Granata, J., Kim, P., Schildhouse, R., & Solomon, G. (2021). Medication reconciliation tool reduces errors in patients admitted from the ed to hospital. American Journal Of Medical Quality : The Official Journal Of The American College Of Medical Quality, 36(2), 129. https://doi.org/10.1097/01.JMQ.0000741500.33781.eb

Honavar S. G. (2019). To err is human, but errors can be prevented. Indian Journal Of Ophthalmology, 67(10), 1517–1518. https://doi.org/10.4103/ijo.IJO_1728_19

James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3), 122–128. https://www.jstor.org/stable/26633011

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Therapeutic Advances In Drug Safety, 11, 2042098620968309. https://doi.org/10.1177/2042098620968309

Patton, J., Monrad, S. U., Zaidi, N., & Abbott, P. (2018). Electronic health record as an educational intervention in medical error reduction. Medical Education, 52(11), 1199. https://doi.org/10.1111/medu.13700

Redmond, P., Grimes, T. C., McDonnell, R., Boland, F., Hughes, C., & Fahey, T. (2018). Impact of medication reconciliation for improving transitions of care. The Cochrane Database Of Systematic Reviews, 8(8), CD010791. https://doi.org/10.1002/14651858.CD010791.pub2

Street, R. L., Jr, Petrocelli, J. V., Amroze, A., Bergelt, C., Murphy, M., Wieting, J. M., & Mazor, K. M. (2020). How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. Journal of patient experience, 7(6), 1247–1254. https://doi.org/10.1177/2374373520925270