A Nurse On A Medical-Surgical Unit Has Made The Same 219649

A Nurse On A Medicalsurgical Unit Has Made The Same Medication Error

A nurse on a medical/surgical unit has made the same medication error two days in a row. As the nurse manager, describe how you would decide whether this is a systems problem or a problem related to the individual nurse. In either case, explain how you (the manager) should correct the problem. Must address the topic. Rationale must be provided. May list examples from your own nursing practice. 2 references minimum 300 words, due Jul 21, 2021.

Paper For Above instruction

The occurrence of repeated medication errors by a nurse on a medical-surgical unit necessitates a thorough investigation to determine whether the issue stems from system deficiencies or individual performance. Properly distinguishing between these causes is crucial for implementing effective corrective actions, ensuring patient safety, and fostering a culture of continuous quality improvement in the healthcare setting.

To decide whether the problem is systemic or individual, a nurse manager should first gather detailed information about the errors. This includes reviewing medication administration records, incident reports, and directly interviewing the involved nurse and other staff members. If the same error occurs because of flaws in the medication management system—such as unclear labeling, confusing protocols, or inadequate staffing—then a systems approach is warranted. Conversely, if the errors stem from factors like fatigue, lack of knowledge, or neglect on the part of the nurse, then targeted individual intervention is appropriate.

Assessing system issues involves evaluating workflow processes and environmental factors. For example, the manager might discover that the medication reordering process is convoluted, or that electronic health records do not flag high-risk medications effectively. Implementing solutions such as standardized protocols, improved technology alerts, or better staffing ratios can minimize human error and create a safer environment. Evidence suggests that system-based approaches, like medication reconciliation and barcode scanning, significantly reduce medication errors (Barker et al., 2002).

On the other hand, if the root cause is related to the nurse’s knowledge or performance, tailored educational interventions, mentorship, or counseling may be necessary. For example, ongoing training about medication calculations and safe administration practices can reinforce correct procedures (Colley et al., 2018). Monitoring performance through direct observation and feedback also encourages accountability and continuous improvement.

Regardless of the identified cause, it is essential that the manager maintains a non-punitive stance to promote transparency and learning. If blame is placed solely on the individual, it may hinder reporting or honest discussions about mistakes. Creating a culture that views errors as opportunities for systemic improvement aligns with patient safety principles advocated by organizations such as The Joint Commission (The Joint Commission, 2020).

In conclusion, differentiating between system and individual causes of medication errors ensures that interventions are appropriate and effective. Implementing system-based solutions reduces the likelihood of human error, while providing targeted education and support addresses individual performance issues. Ultimately, fostering an environment of safety and continuous learning leads to better patient outcomes and staff satisfaction.

References

• Barker, A., Snell, L. M., & Goethe, J. (2002). Implementation of barcode medication administration: A review of the literature. Journal of Nursing Administration, 32(4), 189-197. https://doi.org/10.1097/00005110-200204000-00006
• Colley, K., Smith, S., & Taylor, M. (2018). Improving medication safety with targeted education programs. Nurse Educator, 43(2), 78-83. https://doi.org/10.1097/NNE.0000000000000460
• The Joint Commission. (2020). Sentinel Event Data Root Causes by Event Type 2018-2020. The Joint Commission Sentinel Event Data. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event-data/
• Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
• Horng, H., et al. (2011). Error analysis in medication administration: A systems approach. Journal of Patient Safety, 7(4), 188-194. https://doi.org/10.1097/PTS.0b013e3182298e92
• Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err Is Human: Building a Safer Health System. National Academies Press.
• Landrigan, C. P., et al. (2010). Temporal trends in adverse events in hospitalized patients. New England Journal of Medicine, 363(22), 2089-2090. https://doi.org/10.1056/NEJMc1007674
• Weingart, S. N., et al. (2006). Research in medication safety for hospitalized adults. Medical Care, 44(4), 382–388. https://doi.org/10.1097/01.mlr.0000203570.02995.94
• Leape, L. L., et al. (1998). Transforming hospital patient safety. JAMA, 280(11), 1001-1007. https://doi.org/10.1001/jama.280.11.1001
• Hoffman, R. M., & Cicchetti, D. V. (2008). Establishing a culture of safety: Strategies for health systems. Journal of Nursing Care Quality, 23(4), 300-308. https://doi.org/10.1097/01.NCQ.0000318846.78500.e8