Medication Errors reporting at the community memorial hospital
Problems affecting the community memorial hospital
The main problem for Francis Ballentine is incomplete reporting of medical errors. The problems have extended the negative impact to other areas including hindering the completion of monthly reports. Poor completion of incident reports made it difficult to understand the situation and the extent of problems in the hospital. Some of the reports were not done at the right time and manner while some were not done at all. Besides, the hospital’s procedures were ignored since they were not done consistently or correctly. In this regard, the safety of the patients, organizational reputation, and development were compromised. Legal issues following the poor services to patients and increased medical errors can negatively affect the hospital.
Course of Action
- Ballentine had an opportunity to meet Ms. Ally Ray who was the director of quality improvement to talk about the problem regarding incomplete and incorrect reporting of medication errors. Through the discussion, it was found appropriate to establish a quality improvement team to help in revealing measures that can be taken to address the problem. The gathering information was then compiled to be taken for approval to the quality control council. The Medication Errors Quality Improvement (MEQI) project was then approved to initiate and implement corrective actions.
A team entailing representatives from the pharmacy as well as all the six units in the hospital was involved in the project. The first step was to train the team on the basic TQM/CQI principles by focusing on the PCDA framework. The next meeting was focused on enhancing the understanding of the sources of variation. This was achieved by evaluating the sources of variations based on the current methods in the hospital. The idea was to evaluate the effectiveness and applicability of the methods used to report errors. A checklist of the noted medical errors in July was developed.
Every member was expected to develop a cause and effect chart facilitating the comparison of the performance in July. The third meeting was a continuation of what was done in the second meeting. The daily checklist was compared with what was found in the cause and effect charts. The work helped reveal three important things. It became clear the pharmacy underreported medical error incidents since only 66% were reported. It was noted that the west, southeast, and east units had the poorest reporting in the hospital. Thirdly, medical errors are reduced sharply during weekends. A composite cause and effect chart was then developed where members were expected to vote based on what they consider the two leading causes of medication errors.
Solution and advice to Ms. Ballentine
To address the problem, she must take effective corrective measures. One of the optimal solutions is to develop a training program on reporting errors and arising issues. The training would focus on building reporting skills and motivating nurses to report every occurrence. It should also improve the awareness of medical errors and ensure that everyone understands their negative implication in the place of work. Training would ensure that everyone understands the laid down procedures and determined to follow them (Williams & Savage, 2007). Besides, training would help eliminate vague forms and policies. Training is a form of motivation because staff would understand their expectations and requirements of achieving objectives.
Team training is likely to improve the overall outcome in all the sectors of the hospital. The process should incorporate key considerations including simulation, skill development, active listening, respect to others, outcome measurement, and debriefing on job situations. Ms. Ballentine should note that staff training could improve their ability to respond to issues affecting patients more effectively and efficiently. Their accuracy and quality of care would improve significantly. Apart from playing a role in the reduction of reported errors, the move would lower the rate of medical errors and improve the safety of patients.
Staffing more LPN’s particularly on the weekends is another recommendation to Ms. Ballentine. This should come with Frances’ recognition of the problem and encouraging the provision of tangible feedback. Adequate staffing can help give room for better reporting whenever there is a medical error. Currently, the staff is too busy making it difficult for them to find time to report what is happening. There is lacking time to offer individualized health care because of the high workload. Correspondingly, employing more staff to serve in the hospital can help staff meet their expectations.
Appropriate staffing facilitates the achievement of economic and clinical improvement in the provision of patient care and reporting of errors. Besides, it would also play a role in the reduction of hospital stay, hospital readmissions, and patient mortality. It would also improve safety outcomes through the reduction of hospital-acquired infections, fall incidents, as well as pressure ulcers (Williams & Savage, 2007). Adequate staffing can reduce nurse fatigue and burnouts that affect the reporting of medical errors. Fatigue influences feelings of frustrations and anger that obstruct effective reporting. Ensuring adequate staffing can enable Ms. Ballentine to improve the reporting of medical errors and the overall cost of patient care.
There was a motivational problem at the community memorial hospital since the staff was not oriented or interested in the achievement of the organizational goals. Issues that hindered the motivation of staff included a huge workload because of the staff limitation and lack of desirable skills. Staff was assigned excessive duties increasing chances of making medical errors and underreporting issues whenever they occur. The unfavorable working environment affected the morale of workers losing interest in the job. The management failed in addressing staff concerns resulting in the loss of trust and confidence.
The Community Memorial Hospital was faced with a leadership problem. Although leaders are expected to identify a problem in the systems, they did nothing to identify the problem, possible causes, and solutions to the issue. They failed to take corrective action even though poor reporting of medical errors compromised patients’ experience and organizational reputation. Leaders are expected to improve the workplace environment and motivate their staff to continue offering quality services to patients. However, leaders at the hospital failed to do much in addressing the issue affecting productivity, elimination, and reporting of medical errors.
Lack of a permanent CEO after the firing of the leader two months ago is affecting the operations of the hospital. Dan Jordan, who is the acting CEO, lack sufficient experience in hospital cost accounting. Poor payment of nurses has seen the organization lose experienced nurses to the nearly health facilities. Recruiting qualified nurses has remained a major challenge to the hospital since it does meet the market remuneration for nurses. Working with temporary nursing services has turned even more expensive to sustain. The leadership problem has also heightened the shortage of technicians and lab workers. Besides, the staff has minimal Health information technology (HIT) skills. The organization IT person has little experience and relies mostly on outsourced services. Notably, managers lack appropriate training in performance improvement, management, and leadership. The majority of the staff in the hospital do not have a basic high school diploma.
Williams, E & Savage, G. (2007). Medication Errors reporting at the community memorial hospital. Healthcare management case studies and guidelines