Influencing Quality Within Healthcare

Full Answer Section

Role of the Nurse:

The nurse was responsible for preparing and administering the medication. In this instance, the nurse failed to adequately double-check the medication order against the medication administration record (MAR) and the physician's orders. This lapse in attention to detail led to the medication error.

Role of the Patient in Quality and Safety:

While Mr. Jones did not directly contribute to the medication error, his active participation in his care could have potentially mitigated the situation. If Mr. Jones had been alert and able to question the medication or its appearance, he may have noticed the discrepancy and alerted the nurse.

Relationship Between Patient Care and Outcome:

Fortunately, the medication error was caught during the final medication check by another nurse. The incorrect dose was not administered. This near-miss event, however, highlights the potential for serious harm, such as nephrotoxicity, if the error had gone undetected.

Impact of the Care Environment:

• Nurse Factors: High workload, fatigue, and distractions can contribute to medication errors. In this case, a busy unit and potential distractions may have contributed to the nurse's lapse in attention.  
• System Factors: Inadequate staffing levels, poor medication storage practices, and a lack of robust safety checks within the medication administration process can increase the risk of medication errors.  
• Patient Factors: Patient factors, such as cognitive impairment or language barriers, can also impact the safety of medication administration.  

Quality Model:

While it is unclear whether a specific quality model was explicitly employed in this case, the Swiss Cheese Model can be applied to understand the system failures that contributed to the near-miss event. This model emphasizes that multiple layers of defenses should exist to prevent errors. In this case, the first line of defense (the nurse's double-check) failed. However, the second line of defense (the final medication check by another nurse) successfully prevented the error from reaching the patient.

Actions to Improve Outcomes:

• Strengthening Safety Checks: Implement a robust medication reconciliation process with multiple checks at each stage of medication administration.
• Improving Nurse Staffing: Ensure adequate staffing levels to reduce workload and minimize distractions.
• Implementing a Medication Safety Program: Develop and implement a comprehensive medication safety program that includes regular staff education, safety audits, and root cause analysis of medication errors.
• Utilizing Technology: Implement electronic medication administration records (eMARs) and barcode scanning systems to reduce the risk of medication errors.  
• Patient Education: Educate patients about their medications and encourage them to actively participate in their own care by asking questions and reporting any concerns.  

Conclusion:

This near-miss event underscores the importance of a robust system of safety checks and a culture of safety within healthcare organizations. By implementing the recommended actions, healthcare providers can significantly reduce the risk of medication errors and improve patient safety.

Sample Answer

Summative Assessment: Quality Improvement and Safety Case Study

Scenario:

This case study focuses on a near-miss event involving a medication error in a busy medical-surgical unit.

Summary of the Situation:

A 72-year-old male patient, Mr. Jones, was admitted for pneumonia. He had a history of hypertension, diabetes, and atrial fibrillation. The physician ordered intravenous vancomycin for the treatment of pneumonia. The nurse, preparing the medication, mistakenly drew up 1 gram of vancomycin instead of the prescribed 500mg dose.