Answer for NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit

Medication Administration Errors (MAEs) have been identified as a major threat to patient safety in the hospital, especially in the inpatient medical units. The MAEs in the medical unit have significantly affected patients due to resultant adverse drug events (ADEs), which lead to prolonged hospital stays, morbidity, mortality, and increased medical costs. The proposed safety improvement is a self-reporting program for MAEs. Reporting of MAEs will promote the implementation of appropriate medical interventions to mitigate the effects of the error. The purpose of this assignment is to present an autobiography of scholarly resources to guide in implementing the proposed plan. The resources will help implement the plan in three themes: Common Medication Errors that should be Reported, Barriers to Self-Reporting, and Implementing MAE Reporting.

Annotated Bibliography

Common Medication Errors that Should be Reported

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19, 4. https://doi.org/10.1186/s12912-020-0397-0

The article evaluates the magnitude and factors contributing to MAEs among nurses in tertiary care hospitals. It identifies causative factors such as inadequate training, lack of medication administration guidelines, inadequate work experience, and interruption during drug administration. The article can help identify the probable causes of MAEs in the organization and guide the implementation team in addressing them. The resource is valuable in reducing MAEs since it recommends providing continuous training on safe medication administration, developing and availing a medication administration guideline, and creating an enabling environment for nurses to administer medication safely. Therefore, it can be applied when identifying actions to take when there is an increased number of reported MAEs.

Yousef, A. M., Abu-Farha, R. K., & Abu-Hammour, K. M. (2021). Detection of medication administration errors at a tertiary hospital using a direct observation approach. Journal of Taibah University Medical Sciences, 17(3), 433–440. https://doi.org/10.1016/j.jtumed.2021.08.015

The study examines the prevalence, types, and severity of MAEs and the factors linked with the incidence of MAEs. It identifies that adherence errors are the most frequent MAEs, followed by incorrect drug preparation, and MAEs occur more frequently in non-intravenous administration. The resource can help nurses identify how they are likely to perpetrate MAEs and in what types of medication administration. The article can help reduce MAEs by recommending continuous awareness and education campaigns for nurses on the importance of proper and safe drug administration. It can thus be applied in planning the measures to prevent the recurrence of MAEs after they are reported.

Assunção-Costa, L., Costa de Sousa, I., Alves de Oliveira, M. R., Ribeiro Pinto, C., Machado, J. F. F., Valli, C. G., & de Souza, L. E. P. F. (2022). Drug administration errors in Latin America: A systematic review. Plos one, 17(8), e0272123. https://doi.org/10.1371/journal.pone.0272123

The article examines the frequency and nature of MAEs. The common errors in medication administration identified in the article are wrong time, dose, omission, and administration route. The resource can be helpful to the team that will be involved in implementing the self-reporting program for MAEs. It will help the team to understand what constitutes medication administration errors so that all errors can be recognized and identified. The article is valuable in reducing the risk to patient safety caused by MAEs since it makes providers conscious of errors they may perpetrate when administering medications and identify them when they occur. The resource can enlighten health providers about examples of MAEs to help them understand what events they should report.

Mohammed, T., Mahmud, S., Gintamo, B., Mekuria, Z. N., & Gizaw, Z. (2022). Medication administration errors and associated factors among nurses in Addis Ababa federal hospitals, Ethiopia: a hospital-based cross-sectional study. BMJ open, 12(12), e066531. https://doi.org/10.1136/bmjopen-2022-066531

The article evaluates the magnitude and factors contributing to MAEs among nurses in federal hospitals. It identifies that MAEs occur in the following ways: wrong patient, wrong medication, wrong dose, wrong route, wrong time, wrong drug preparation, wrong advice, wrong assessment, and wrong documentation. The resource can help the implementation team when educating nurses on the type of MAEs and the incidences they should report. The article is valuable in promoting patient safety since it identifies common causes of MAEs perpetrated by nurses. This can be used to identify evidence-based measures that can be implemented to address the causes of reported MAEs.

Barriers to Self-Reporting

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research, 21, 1-10. https://doi.org/10.1186/s12913-021-07187-5

The article identifies and assesses the barriers limiting nurses from reporting MAEs in the hospital setting. It identifies organizational barriers like inadequate reporting systems, management behavior, unclear definition of a medication error, and individual barriers like fear of management/lawsuit and inadequate knowledge of MAE. The resource is valuable to the implementation team in identifying factors that may hinder nurses from reporting errors. The article proposed measures to address the barriers, such as providing an enabling environment without punitive measures and blame. This can be used to encourage nurses in the organization to report MAEs.

Nkurunziza, A., Chironda, G., Mukeshimana, M., Uwamahoro, M. C., Umwangange, M. L., & Ngendahayo, F. (2019). Factors contributing to medication administration errors and barriers to self-reporting among nurses: a review of literature. Rwanda Journal of Medicine and Health Sciences, 2(3), 294-303. https://doi.org/10.4314/rjmhs.v2i3.14

The resource assesses the contributing factors linked to MAEs and barriers to reporting among nurses. It identifies heavy workload as the main factor contributing to MAEs and fear of blame as the main barrier to self-reporting. Thus, the article can help the implementation team understand the primary factors contributing to MAEs and those limiting self-reporting so that they can be addressed before executing the plan. The resource promotes patient safety by recommending that organizations address heavy workloads to decrease MAEs and foster a non-punitive environment to encourage self-reporting of MAEs. It can be applied when identifying measures to reduce the number of reported MAEs and increase voluntary reporting.

Bovis, J. L., Edwin, J. P., Bano, C. P., Tyraskis, A., Baskaran, D., & Karuppaiah, K. (2018). Barriers to staff reporting adverse incidents in NHS hospitals. Future healthcare journal, 5(2), 117–120. https://doi.org/10.7861/futurehosp.5-2-117

The article examines barriers to reporting adverse incidents (AIs). It identified that most providers fail to report AIs because of poor response or failure to receive feedback from previous reports. The resource can help the implementation team understand that giving constructive feedback is crucial once a nurse has reported an MAE. The article found that training and feedback after reporting are two main factors that can improve confidence in and use of AI reporting. The resource can be applied when identifying ways to increase nurses’ confidence in MAE reporting.

Mohamed, M. F., Abubeker, I. Y., Al-Mohanadi, D., Al-Mohammed, A., Abou-Samra, A. B., & Elzouki, A. N. (2021). Perceived Barriers of Incident Reporting Among Internists: Results from Hamad Medical Corporation in Qatar. Avicenna Journal of Medicine, 11(03), 139–144. https://doi.org/10.1055/s-0041-1734386

The article examines the practice and identifies the barriers linked to incident reporting among internal medicine physicians. It identifies the main barriers to reporting incidents: unawareness of incidence reporting, the perception that incidence reporting will not contribute to a system change, and the fear of retaliation. The resource will aid the implementation team in understanding barriers that may limit nurses from reporting MAEs. This will guide them in identifying strategies to mitigate these barriers before implementing the plan and encourage error reporting. Besides, the resource can be used when error reporting has declined to establish the likely causes.

Implementing MAE Reporting

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., … & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046

The article discusses medication error reporting culture, incidence reporting systems, developing effective reporting methods, analysis of medication error reports, and recommendations to enhance medication error reporting systems. It provides valuable information to the MAE reporting program implementation team on how it can create effective reporting methods and improve reporting of MAEs when executing the plan. Besides, the resource is valuable in reducing MAEs since it recommends that health organizations create an effectual reporting environment for the medication use process. The resource can be used in creating a successful medication error reporting program that is safe for the reporter and includes all providers, leading to constructive and helpful recommendations and effective changes.

Linden-Lahti, C., Takala, A., Holmström, A. R., & Airaksinen, M. (2021). What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety? Journal of patient safety, 17(8), e1179–e1185. https://doi.org/10.1097/PTS.0000000000000914

The study examined reported severe medication errors (MEs) and assessed how incident documentation applies to learning from errors. The resource can provide insights to the implementation team that the reported MEs provide a valuable source of risk information. They should be used for learning and taking action to prevent severe errors in the future. The article is valuable in promoting patient safety since it recommends that organizations take action to improve medication safety and investigate reported errors to prevent recurrence.

Dhamanti, I., Leggat, S., Barraclough, S., & Tjahjono, B. (2019). Patient safety incident reporting in Indonesia: an analysis using World Health Organization characteristics for successful reporting. Risk management and healthcare policy, 331-338. https://doi.org/10.2147/RMHP.S222262

The study examined the level to which a patient safety incident reporting system has adhered to the WHO characteristics for successful reporting. The article will provide insights to the MAE reporting program team on the characteristics the hospital reporting system should have to meet the WHO criteria. The article explains the characteristics of an ideal program, including A non-punitive system, confidentiality, timeliness of reporting, expert analysis, system orientation, and responsiveness. Thus, the team should implement these for a successful self-reporting program to promote patient safety.

Woo, M. W. J., & Avery, M. J. (2021). Nurses’ experiences in voluntary error reporting: An integrative literature review. International journal of nursing sciences, 8(4), 453–469. https://doi.org/10.1016/j.ijnss.2021.07.004

The article examines nurses’ experiences with voluntary error reporting (VER) and the factors influencing their decision to participate in VER. It establishes that institutional efforts are crucial towards improving nurses’ recognition, reception, and contribution towards voluntary error reporting. The article can help the organization understand the measures it should take to encourage nurses and providers to report medication errors voluntarily. Nurse leaders can use this article tool to prioritize and invest in measures to improve existing organizational error management approaches and establish a just and open patient safety culture. This will promote a positive experience among nurses towards error reporting.

Conclusion

The annotated bibliography examines peer-reviewed articles focusing on MAEs. The articles discuss common MAEs, factors contributing to MAEs, barriers to self-reporting errors, and factors promoting successful self-reporting programs in hospital settings. The resources are valuable to the implementation team for the proposed self-reporting program for MAEs since they provide insights into the barriers they may face, how to address them, and how to foster the program’s success.

Answer for NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit