The primary concern of the healthcare industry is patient safety, where treatment, well-being, and security of lives directly align with safe care. In this context, healthcare professionals try their level best to deliver impeccable medical services to gain the desired goals regarding health. However, the complexity of the system and fast-paced demands may lead to various errors that create safety threats. So, addressing patients’ safety issues has become crucial to reducing harm, improving the quality of healthcare, and maintaining trust in the system. Otherwise, the consequences and implications of such errors and mistakes become manifold if not properly addressed. So, a deeper understanding of safety issues is mandatory for handling patient safety appropriately. Such understanding may encompass the identification of potential safety issues and respective impacts by considering all stakeholders. However, this paper will explore a safety issue, i.e., medication error, along with associated risks, the results of not addressing the issue, the role of multiple regulatory agencies in this context, and multiple evidence-based tools and strategies to tackle the said threats effectively.
Health Care Safety Imperative
The identified potential safety threat from the available list is medication error, which is solely the incorrect administration of any medicine to a particular patient. The multiple dimensions of medication error may include selection of the wrong medicine due to any reason, incorrect dose, incorrect route for medicine administration, or delivery of medicine to the wrong patient (Sutherland et al., 2020). For example, a nurse administers an antihypertensive medicine to patient B that is actually intended for patient A. Patient B was admitted with different conditions compared with patient A, but their names were similar, which led to confusion during dosage administration. In this case, the concerned nurse did not utilize a verification system and relied on her memory, which intensified the said situation.
However, medication errors may lead to severe implications. The foremost consequence of such a medication error is harm to the patient. Such incorrect administration may cause worsening conditions for the patient, even life-threatening outcomes. Another result would be the legal action that the concerned patient or family may take against the healthcare facility. Such legal action will lead to reputational damage, financial loss, and several penalties imposed on healthcare units according to law. Similarly, such incidental medication errors rupture the trust of patients and clients in the healthcare system, staff, and officials. This result is observable during follow-up treatments and even in the future when patients are reluctant to take any services. In addition, several other consequences would be the imposition of penalties by regulatory bodies, decreased morale of the staff, and a tarnished reputation of a particular healthcare facility in the long run. However, addressing medication errors is crucial to prevent the aforementioned impacts.
Risks If Threats Are Not Addressed
Multiple risks are associated with situations where patient safety threats are not addressed in healthcare systems. Such risks may be severe and leave multiple impacts on various stakeholders. For example, the greatest risk lies with the patient, who is the most vulnerable in such medication-error cases. Adverse medication reactions may sometimes lead to life-threatening situations, and the patient’s life is endangered. Such risks to the lives of patients become severe if the safety threat is not addressed as a first priority. Similarly, another stakeholder under the blanket of risk is employees. All healthcare professionals, including physicians, the nursing community, and support staff, have to bear multiple risks. These may include emotional distress, augmented stress, and job loss. In addition, an unaddressed patient safety threat poses severe risks and implications for organizations. These include risks of legal impacts, fines, reputational loss, and low turnover in the future, along with bans by regulatory agencies.
However, in such cases of medication error, the healthcare imperative emphasizes that the leading purpose of healthcare operations should be safety. It implies following medication-administration protocols, creating a safe environment, and using modern technology and techniques. By adhering to the safety imperative, medication errors may be minimized to the greatest extent. In addition, various regulatory bodies and agencies are working in the country to oversee patient safety issues. The list comprises CMS (Centers for Medicare & Medicaid Services), The Joint Commission, FDA (Food and Drug Administration), and AHRQ (Agency for Healthcare Research and Quality), along with multiple State Health Departments, etc.
Regulatory Agency Role and Impact
In healthcare organizations, regulatory authorities play a crucial role in enforcing patient safety standards. They aim to ensure that healthcare facilities prioritize patient safety and quality care. For example, concerning medication error, NPSGs (Joint Commission’s National Patient Safety Goals) outline particular areas to improve patient safety through correct identification of patients and prevention of infections. Hence, regulatory authorities have significant impacts on safety programs as well. All healthcare facilities are required to comply with the enacted rules and regulations for accreditation purposes, reimbursement of funds from the government, and avoidance of any legal penalties. As a result, the respective organizations align their initiatives with the guidelines enacted by regulatory agencies.
Meanwhile, healthcare organizations incorporate the guidelines of regulatory agencies to develop and investigate best practices. These practices ensure patient safety standards like the implementation of an incident-reporting system. Through such a system, employees report adverse incidents, mishaps, and concerns of patients. Such a system should be nonpunitive to promote a culture of open discussion, where the concerned staff should report any error, safety issue, and wrong practice without fear. Similarly, to incorporate agencies’ guidelines, health organizations should establish concrete investigation protocols to analyse any reported incident or issue. These protocols may involve the identification of root causes, conducting thorough reviews, devising corrective actions, and the implementation of various checks to prevent such incidents in the future. In such a manner, healthcare organizations may overcome risks and enhance patient safety to the maximum extent.
However, the consequences would be drastic for employees, patients, and even organizations if the respective hospitals fail to rectify threats. Patients may suffer from complications and threats to life, while employees may experience job dissatisfaction along with issues in future careers. Similarly, organizations may experience penalties, fines, cancellation of registrations, and a reduced flow of patients. However, hospitals have concrete options to prioritize patient safety and incorporate regulatory agencies’ regulations into the system to avoid any discrepancy.
Role of the Patient Safety Officer
Patient safety officers play a crucial role in implementing patient safety plans in healthcare organizations. They develop and oversee strategies such as collaborating with all stakeholders, conducting training, and evaluating overall safety initiatives. They also tend to establish a culture where errors can be reduced. In this way, their main responsibilities revolve around the identification of safety issues like medication errors, devising plans, and implementing them according to the policies of the organization. Mulac et al. (2021) concluded that patient safety officers reduce patient safety threats by checking medication errors as they formulate and devise the particular mechanism that leaves lasting impacts.
Evidence-Based Best Practice Tools
To eliminate and reduce patient safety threats, the use of evidence-based practice tools and techniques becomes necessary. Currently, multiple recommendations in this regard play a significant role and have lasting impacts. These practice tools include “Medication Barcoding Systems,” which reduce medication errors through scanning applications. Kuitunen et al. (2021) concluded that barcode scanning has the ability to reduce medication errors by about half. Similarly, “Medication Reconciliation” is another tool recommended by AHRQ (Agency for Healthcare Research and Quality). In addition, other tools may be “Team Training and Communication,” “Incident Reporting and Root Cause Analysis,” and “Standardized Protocols and Checklists,” which reduce medication errors significantly.
Moreover, to reduce patient safety threats, a five-point plan is of grave importance. The first point is the implementation of a barcoding system on a priority basis. Meanwhile, during patient transitions of care, a standardized medication-reconciliation process is the second point. The third point relates to team training sessions on a regular basis to improve collaboration and prevention of errors. Similarly, the fourth point is the propagation of a culture of reporting any incident and considering root-cause analysis to reduce threats in future cases. Finally, the fifth point is the development and adoption of standardized procedures like abiding by the safety checklist during the medication process.
Furthermore, various process considerations can be helpful in eliminating patient safety threats. For example, responding appropriately and providing feedback help ensure suitable actions. Similarly, regular rounds by senior staff to identify potential threats may be helpful. Another consideration may be the use of technology for detecting and alerting the healthcare system about any threat. In addition, reporting the ongoing situation with discussion-based suggestions is significant. Finally, operational considerations such as wise allocation of resources, taking initiatives, adoption of new procedures, and use of modern technology can reduce patient safety threats.
Conclusion
From the above discussion, it can be concluded that patient safety issues are of grave importance in the healthcare system. Medication errors pose severe effects on the health and lives of patients, the overall morale of employees, and the business model of concerned hospitals. However, the healthcare imperative emphasizes that healthcare organizations should address safety issues to prevent discrepancies. In this context, the role of regulatory agencies and safety officers is pivotal, along with the implementation of evidence-based practice tools and various considerations. All such measures are significantly helpful in reducing and eliminating patient safety threats to make healthcare organizations safer, more secure, and more productive.
References
Kuitunen, S. K., Niittynen, I., Airaksinen, M., & Holmström, A. R. (2021). Systemic defenses to prevent intravenous medication errors in hospitals: a systematic review. Journal of Patient Safety, 17(8), e1669.
Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy, 28(e1), e56-e61.
Sutherland, A., Canobbio, M., Clarke, J., Randall, M., Skelland, T., & Weston, E. (2020). Incidence and prevalence of intravenous medication errors in the UK: a systematic review. European Journal of Hospital Pharmacy, 27(1), 3-8.
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