Risk Management and Safety: Medication Errors

Slide 1: Introduction
 It is impossible to exaggerate the value of risk management in the healthcare industry.
 Risk management is a constant operational obligation in hospitals, nursing homes,
mental health facilities, and private practices.
 Although patient safety is the primary emphasis of healthcare risk management, its range
goes beyond reducing medical errors.
 As a result, risk management specialists play a crucial role in healthcare administration
and advise those making decisions about operations, finances, training, clinical
procedures, and other issues.
Speaker Notes:
 The eight functional areas or domains of enterprise risk management are as follows:
operational, clinical and patient safety, strategic, financial, human capital, legal and
regulatory, technological, environmental and infrastructure hazards. Nonetheless, our
study focuses on medication errors as one of the safety issues under clinical and patient
safety.
 Clinical risks include mistakes that harm patients or personnel but are identified in time
to prevent harm. Through the mitigation of harm and prevention of medical errors,
enterprise risk management processes guarantee patient safety (Wei et al., 2020).
 Clinical risk managers study medical errors to pinpoint the underlying reasons and set up
procedures to prevent them from happening again.
Slide 2: Importance of risk management and quality assurance within clinical healthcare
environments

 Quality control and risk management are essential elements of clinical healthcare
settings.
 They are essential for sustaining organizational integrity, guaranteeing patient safety,
and enhancing healthcare results.
 The following are the main justifications for risk management and quality assurance: to
ensure patient safety, Compliance with Regulatory Standards and Guidelines,
Continuous Improvement, cost reduction, and to enhance Organizational Reputation and
Trust.

Speaker Notes

 Risk management and quality control are essential for sustaining corporate credibility
and confidence, adhering to rules, promoting continuous improvement, and lowering
costs (Wei et al., 2020). Healthcare organizations may improve overall care quality,
reduce risks, and improve patient outcomes using effective risk management strategies
and quality assurance systems.
Slide 3: Quality/Safety Issue: Medication errors.
 Medication errors are one inefficiency and failure that can cause issues with quality or
safety in a clinical setting.
 Medication errors happen when the procedure of administering the drug fails, resulting in
the administration of the incorrect medication, dose, or route.
 The quality of care and the safety of the patients may both be significantly impacted by
this problem.
 Medical errors lead to patient harm, worsened health outcomes, decreased trust and
satisfaction, increased healthcare costs and legal and regulatory consequences.
Speaker Notes
 In summary, medication errors substantially impact the standard of care and patient
safety in a clinical setting. They have an immediate effect on patients' health, lead to
poorer health outcomes, undermine patient confidence and happiness, raise healthcare
costs, and have legal and regulatory repercussions. Preventing and addressing drug errors
is essential for maintaining high-quality care delivery, protecting patients, and enhancing
healthcare outcomes (Galindo et al., 2023).
Slide 4: Effects of Medication Errors at Point of Care
 Medication mistakes can have a negative effect on a patient's health and well-being right
at the point of care.
 At the point of care, medical errors can increase side effects and allergic reactions among
patients.
 Furthermore, medical errors increase hospital readmissions and worsen the situations of
patients, thus increasing mortalities.

Speaker Notes:
 At the point of care, incorrect dosage or medicine administration might result in serious
side effects, allergic reactions, or even fatal complications. In order to address the effects
of the mistake, patients may experience a worsening of their illness, extended hospital
admissions, or the need for extra medical measures. Furthermore, medication errors can
undermine patient trust in healthcare professionals and organizations, which lowers
patient satisfaction and treatment plan adherence (Etges et al., 2019).
Slide 5: Effects of Medication Errors at the Organization Level
 Similarly, medication errors can have a variety of effects on an organization :
 It raises the medical expenses of the organization.
 Harms the reputation of the organization.
 Increases the demand for healthcare resources within the organization.
Speaker Notes
 At the organizational level, medical errors may contribute to rising medical expenses.
Errors in medicine administration may need extra medical procedures, extending hospital
stays and raising the demand for healthcare resources. Besides, drug errors can have
financial consequences for healthcare companies in the form of possible lawsuits and
legal sanctions.
 Additionally, medical errors can harm the hospital's standing in the community.
Medication mistakes can soon become public knowledge, hurting the organization's
reputation and trust. A decline in the number of patients and referrals may affect the
organization's ability to remain financially viable and achieve overall success (Sarfati et
al., 2019).
Slide 6: Guideline to Mitigate Risk or Assure Quality: "National Patient Safety Goals"
(NPSGs)
 The "National Patient Safety Goals" (NPSGs) created by The Joint Commission are one
healthcare regulatory guideline that offers guidance regarding pharmaceutical errors in
the clinical setting.
 Among the NPSGs goals are three goals that focus on medication safety.
 The three goals are:
i. Identifying patients correctly.
ii. Improving communication.
iii. Using medicines safely.
Speaker Notes
 The Joint Commission is a reputable accrediting authority for healthcare organizations in
the US. By identifying problem areas and outlining clear standards for healthcare
organizations to meet, the NPSGs seek to increase patient safety and the standard of care.
 Three goals of the NPSGs are concerned with pharmaceutical safety. The guidelines'
expectations state the following: Correctly identifying patients to ensure proper patient
identification prior to medicine administration, healthcare organizations are required to
utilize at least two patient identifiers, such as name and date of birth.
 Furthermore, according to the guideline, healthcare practitioners must communicate
effectively with one another to reduce prescription errors. The recommendation strongly
emphasizes the value of established procedures for oral and written communication,
particularly when it comes to the transfer of medical information.
 The third goal is safe medication use. This expectation covers providing patients with
information about their prescriptions, properly labelling medications, and lowering the
possibility of medication-related problems. In order to avoid mistakes, healthcare
institutions are recommended to have policies in place for high-risk drugs like
anticoagulants or opioids (Sarfati et al., 2019).
Slide 7: Three Variables within the clinical setting which can influence the NPSGs
guidelines
 Compliance with the NPSGs guidelines can be influenced by three variables within the
clinical setting:
i. Workload and staffing levels.
ii. Communication and collaboration.
iii. Technology and systems approach.
 These factors can be addressed by developing a comprehensive strategy involving hiring
enough people and managing their workloads, encouraging open communication and
teamwork, and spending money on dependable, user-friendly technology solutions.
Speaker Notes
 Variables in the clinical situation can have an impact on whether these expectations are
met.
 Among the variables are workload and personnel numbers: Healthcare professionals may
experience greater stress and time strain due to heavy workloads and insufficient staffing.
Healthcare personnel may be more prone to prescription mistakes when their job
overburdens them. Medication errors can be exacerbated by inadequate staffing levels,
which can also restrict access to resources like automated dispensing cabinets or systems
for reconciling medications (George & Jacob, 2020).
Slide 8: Three Variables within the clinical setting which can influence the NPSGs
guidelines cont.
 Communication and collaboration are other factors that influence the guidelines.
 Effective communication and teamwork among healthcare professionals are crucial for
ensuring the safety of pharmaceuticals.
 Technology systems support is another variable influencing compliance with the NPSGs
guidelines.

Speaker Notes
 Another variable is communication and collaboration. The exchange of crucial
prescription information might be hampered by factors like hierarchical structures, poor
inter-professional communication, and poor teamwork, which raises the risk of mistakes.
Compliance with medication safety recommendations can be significantly influenced by
a culture that values open communication and promotes inter-professional collaboration
(Boggs, 2022).
 Furthermore, the accessibility and usability of technology and systems to assist drug
safety can greatly impact how strictly rules are followed. Medication errors can be
decreased with electronic health record (EHR) systems that provide features like clinical
decision assistance, barcode scanning, and alerts for possible drug interactions. However,
 out-of-date or improperly developed technological systems might obstruct safe medical
procedures and raise the risk of mistakes.
Slide 9: Quality Improvement Model: PDSA Model
 The Plan-Do-Study-Act (PDSA) cycle is one quality improvement strategy that can
reduce medication errors and boost quality and safety in the clinical context.
 A systematic method frequently used in healthcare to adopt and assess changes for
quality improvement is the PDSA cycle.
 There are four essential steps in the PDSA cycle:
i. Plan
ii. DO
iii. Study
iv. Act
Speaker Notes
 Healthcare organizations might use the PDSA cycle to develop, evaluate, and improve
improvements to address pharmaceutical errors and adhere to recommendations.
 By enabling healthcare organizations to test interventions under controlled conditions and
make data-driven decisions, PDSA supports evidence-based practice and encourages
continuous quality improvement.
Slide 10: PDSA Model cont.
 Plan: In this step, healthcare professionals create a change plan, establish definite goals
and pinpoint an area that needs improvement.
 Do: The "Do" step is putting the planned change into practice on a limited scale or in a
supervised setting.
 Study: Data gathered during the implementation phase is analyzed in the "Study" step to
assess the results and effects of the change.
 Act: Based on the data analysis, the "Act" step involves choosing whether to embrace,
adapt, or discard the change.

Speaker Notes

 At the planning stage, the healthcare practitioners must acquire pertinent data, evaluate
the procedures in place and find viable interventions to address medical errors. The "Do"
stage will enable healthcare professionals to monitor the effects of the adjustment and
compile information on its effectiveness. Healthcare practitioners can, for instance, test-
drive a brand-new prescription reconciliation procedure or roll out barcode scanning
equipment in a particular unit or division (England, 2021).
 During the study phase, the organization's management will examine whether the
adjustment reduced medication errors, increased patient safety, or produced other desired
 effects is part of this process. The study reveals trends, patterns, and areas that require
more development.
 At the act phase, the organization will make a more extensive adjustment if the initial one
was successful and improved medication safety. If the adjustment does not provide the
expected results, the intervention can be modified, and the PDSA cycle can be repeated
(England, 2021).

Slide 11: PDSA Model cont.

 The PDSA cycle can be used to test and implement particular treatments to adhere to the
regulatory, accreditation, or evidence-based practice criteria linked to pharmaceutical
safety.
 Healthcare organizations might use the PDSA cycle to develop, evaluate, and improve
improvements to address pharmaceutical errors and adhere to recommendations.
 PDSA supports evidence-based practice and encourages continual quality improvement
by enabling companies to test interventions under controlled conditions and make data-
driven decisions.
Speaker Notes
 Under the planning stage, the organization can comply with regulatory guidelines by
breaking down the pharmaceutical safety recommendations that healthcare practitioners
want to address into individual components, such as patient identification or
communication procedures. They can then create a strategy to change those areas, such as
introducing a standard procedure for patient identification or enhancing communication
tools (England, 2021).
 At the "Do" stage, the anticipated modifications can be tested in a small department or
unit, allowing medical professionals to see how they affect the safety of prescribed
medications. For instance, they can set up organized communication protocols for drug
handoffs or use barcode scanning technologies for medicine administration (England,
2021).
 During the study phase, the improvements' impact on medication mistakes, patient
identification, communication, and other desirable outcomes can be evaluated by
healthcare providers. Patient satisfaction surveys, incident reports, prescription mistake
rates, and staff evaluations are a few data sources.
 At the final phase, "Act," healthcare professionals can decide whether the changes
comply with regulatory requirements and improve pharmaceutical safety based on the
data analysis. If the modifications are successful, they can be implemented more broadly
across the organization. Revisions can be made to hone the interventions further, and the
PDSA cycle can be repeated.
Slide 12: Nurse Leader Competencies Which Promote a Culture of Quality and Safety
  When it comes to the problem of medication errors, three distinct nurse leader
competencies can be used to reduce risk and advance quality and safety:
i. Effective communication.
ii. Clinical Knowledge and Expertise.
iii. Ethical Decision-Making.
Speaker Notes
 To foster a culture of quality and safety, effective communication is essential. Strong
communicators, such as nurse leaders, can help healthcare team members communicate
clearly and succinctly, ensuring that vital drug information is appropriately relayed.
Promoting quality and safety requires nurse leaders with a high degree of clinical
knowledge and proficiency in drug management. They can advise and instruct staff
members on safe pharmaceutical administration methods, including dosage calculations
and medication reconciliation procedures. Besides, Strong ethical decision-making
abilities in nurse leaders allow them to successfully handle challenging circumstances
with medication safety (Rodziewicz & Hipskind, 2020).
Slide 13: Nurse Leader competencies cont.
 Nurse leaders can foster a culture that encourages quality and safety in relation to
medication errors by exhibiting effective communication, clinical knowledge and
experience, and ethical decision-making.
 They can persuade personnel to follow legal requirements, accrediting standards, and
evidence-based medication safety measures.
 Nurse leaders should ensure that staff members have access to the information and tools
they need to avoid medication errors by establishing clear communication channels,
providing education, and providing support.
 Nurse leaders are essential in reducing risks and building a culture of quality and safety
in administering medications by supporting safe practices, addressing system-level
problems, and fostering a culture of openness and accountability.
Speaker Notes
 Nurse leaders can encourage the use of standardized communication methods during drug
handoffs, such as SBAR (Situation, Background, Assessment, Recommendation) to
reduce the risk of medical errors. Nurse supervisors can encourage staff to report
medication errors or near misses by promoting open and honest communication (Dirik et
al., 2019). This will help identify problems quickly and find solutions.
 Furthermore, nurse leaders may ensure their staff is prepared to avoid medication errors
by remaining current on evidence-based recommendations and best practices. They can
facilitate continuous education and training sessions to reinforce safe medication
practices and address any knowledge gaps or new problems.
 In addition, a culture that promotes ethical considerations and supports patient-centred
care can be created by nurse leaders. For instance, a nurse leader can advocate for
 essential reforms and distribute resources effectively if they become aware of systemic
problems, such as insufficient staffing or obsolete technology, that contribute to
prescription errors. Additionally, nurse leaders can promote a culture of psychological
safety and professional responsibility by encouraging and assisting employees in their
ethical duty to speak out about potential drug errors or safety concerns (Irajpour et al.,
2019).
Slide 14: Conclusion
 In conclusion, medication mistakes in clinical settings can seriously jeopardize the
quality of the treatment given to patients and their safety.
 They affect patient outcomes and satisfaction at the point of care as well as organizational
expenses, reputation, and legal concerns related to healthcare.
 Improving patient safety and sustaining high-quality care depends on proactively
addressing drug mistakes.
 Healthcare companies should implement thorough protocols and procedures for
medication safety to address this problem.
 The standardization of prescription delivery procedures, the use of barcode scanning
technology, and the encouragement of healthcare personnel to report and learn from
pharmaceutical errors are just a few examples of how medication errors can be
minimized in the healthcare sector.
 For healthcare professionals to be able to administer pharmaceuticals safely, it is essential
to provide them with the knowledge and training they need.
 The NPSGs give healthcare organizations a legal foundation for promoting
pharmaceutical safety. However, several elements in the clinical setting, including
workload and staffing, communication and teamwork, and technology and system
support, might impact adherence to these standards.
 It is essential to recognize and deal with these factors to ensure adherence to the
instructions and enhance patient safety.
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