NURS FPX 4010 Assessment 2 

Interview and Interdisciplinary Issue Identification

Name

University

Prof. Name

Date

Introduction

A pharmacist ensures that patients are safe, particularly in the management of medicines within a community health clinic. More often than not, however, one life-threatening issue has been arising: medication errors due to poorly designed labels and packages. Such errors typically result in life-threatening consequences for a patient in the form of incorrect dosage, unpleasant reactions, and even a decrease in the overall treatment efficacy (Cohen, 2007). This way, much will be achieved in bettering patient conditions and building trust in healthcare provision. By so doing, therefore, write an assignment that seeks to elicit views from a physician or a nurse about the set problem, find out their challenges, and work in collaboration to come up with workable solutions. This is upon the call to establish the root causes and utilize evidence-based strategies upon what will better the precision and safety of the administration of drugs in the clinic (Vredenburgh & Zackowitz, 2008). It is, therefore, obligatory to collaborate to inculcate a safer and much reliable environment in health care.

Interviewee Selection and Background

I interviewed Dr. Jane Thompson who has been practicing for more than fifteen years as a physician at our community health clinic and I interviewed her through a face-to-face conversation. Dr. Thompson is aware of the clinic’s work and has witnessed numerous cases of medication errors with her own eyes. She has provided a very useful viewpoint in assessing the root of such mistakes and the right approach to them. Being a practicing physician, the roles and responsibilities of Dr. Thompson entail not only prescription of the drugs but also the supervision of the management and care of the patients, thus making her perception useful in medication safety (Berman, 2004).  

 Some of the daily challenges as narrated by Dr. Thompson include the problem of labeling and packaging of the medications that causes confusion to the patients and the staff. Her case shows that communication should be clear and any products that are similar should be named differently. Therefore, during this interview, it will be possible to identify some of the issues and align our activities in order to enhance the safety of medications in our clinic. Analyzing Dr. Thompson’s case, his specialization and patient centered approach allow to define the existing issues and potential improvements in the process of medication management (Fewster-Thuente & Velsor-Friedrich, 2008). They will be of great help in the formulation of strategies to prevent and reduce medication errors and improve on patient care.

Identifying Medication Errors

Dr. Jane Thompson listed many medication errors she encountered because of inadequate labeling and packaging. One of the main reasons is the same color and design of the packages; the pharmacist may mistakenly serve it. For instance, some drugs have the same color and design packaging, which causes confusion between the patients and the doctors (Lockhart & Paine, 1996). Dr. Thompson remarked that even with minor names of medications differing, an error became pretty significant in a busy clinical environment where decisions often have to be made very quickly.

Another common mistake is the unclearly labeled or non-labeled medicines. Most of the time, such critical information that is supposed to be on the dosage, expiring date, or any patient-specific information is omitted or not put into emphasis. This lack of clarity means that patients may take the wrong dose or out-of-date drugs, which is compromising their treatment. Dr. Thompson gave an example, substantiating the need for multilingual labeling in a community clinic in which to ensure all patients understand their prescription instructions in a transparent manner.

She also underscored that technology had also managed to play its part in augmenting and abating errors in medication. While EHRs could reduce errors because all the information about a patient will be stored online, not being used accordingly, or not integrated into the clinic’s work process, frequently became an issue of erroneous entries and miscommunications about the information entered among the staff. On the other end, with regard to the use of EHRs, while electronic health information systems could reduce errors. Dr. Thompson believes that the issue is being addressed through various strategies, such as better labeling standards, improved packaging practices, and better use of technology to ensure accurate medication dispensing and administration, among others (Measuring Medication Errors, 2015).

Analysis of Medication Labeling and Packaging Issues

Medication labeling and packaging problems have some critical issues in contributing to medication errors both at the community household level and in our community health clinic. One such crucial factor is non-standardization among the various stakeholders. For instance, differences in font sizes, color schemes, and placements of information are likely to confuse both the healthcare provider and the patient, thereby fostering errors in medication (Turkoski, 2009). The standardization of those elements would get rid of those mistakes and protect against them, with all necessary information available and retrievable for the consumer.

Dr. Jane Thompson said that typical of the existing packaging, it ignored the practicalities of a busy clinical environment. For example, blister packs that are difficult to open or labels peeling off all too easily with frequent handling can interfere with the safe administration of medicines (Cohen, 2007). Improper packaging can also lead to storage places where medicines are mixed up, mistakenly misplaced, and thus raising the risk of errors even further.

In addition, Dr. Thompson noticed that there have to be included full and clear instructions on a medication’s label. This refers to both its administration and dosage, as much as its possible side effects and interactions with other medicines. The absence of those crucial pieces of information may lead to the misuse of drugs and adverse reactions, especially in patients taking several prescriptions at once (Apold et al., 2006). Another area to explore further is multilingual labeling, particularly in cultural communities where patients may not be able to read the language of the labeling most commonly used.

The technological aspect plays a vital role in these challenges. Technology interfaces allow for advanced labeling systems that make them compatible with electronic health records in orderly updating to explain current and relevant patient information and the most current medication guidelines available. Administration medication barcode systems essentially reduce errors by ensuring patients receive the proper medication at the right time.

These labeling and packaging challenges need to be overcome through the collective effort of healthcare providers, regulatory bodies, and the pharmaceutical industry. Overcoming the deficiency in standard labeling practice, enhancing packaging design, and the extensive use of technology can transform measures for bringing down medication errors and increasing patient safety at the clinic (Al-Worafi, 2023). This measure will instill the development of safe and secure healthcare and confident patient outcomes, as well as a more trusted healthcare system.

Evidence-Based Interdisciplinary Approach to Address Medication Errors

To avoid medication errors due to bad labeling and packaging, it is necessary to implement an evidence-based interdisciplinary approach. This approach involves the use of pharmacists, physicians, and nurses to come up with a comprehensive plan that would help in improving medication safety.

 One of the most important strategies is the use of templates in communication, for example, the SBAR model. This in a way makes it possible to provide clear and consistent information about medications to different health care practitioners thus minimizing chances of errors (Apold et al. , 2006). Moreover, training programs aimed at teaching staff the best practices of using such tools as well as the means of effective communication and collaboration can encourage the implementation of such technologies.

 Technology is also used in this interdisciplinary approach. Automated labeling systems that interface with EHR can assist in delivering accurate and current information, which will help to maintain the medication labels up to date with the guidelines and patient’s information. (Hughes, 2008).  Medication administration through bar code scanning systems ensure that the right medication is given to the right patient at the right time thus minimizing on the errors.

 Also, educating patients and providing clear instructions on the process of medication management makes them more responsible for their treatment. Multilingual labels and educational materials are also important to guarantee that all patients are aware of their medications and its possible misuse and side effects (Institute of Medicine et al. , 2007).

 Thus, the implementation of the SCM framework with the focus on the standardization of communication, technology integration, and patient engagement can lead to the reduction of medication errors in community health clinics (Simas, 2022). This is important to establish a sound and efficient health care system because of the need to collaborate.

Change Theory and Leadership Strategy

Another way to deal with medication errors effectively is necessary to use a change theory and a strong leadership approach. The PDSA cycle is a useful approach to implementing change in settings such as healthcare organizations. This cyclic process of planning, executing, evaluation and improvement of practice is also known as Plan-Do-Study-Act cycle (2004). Applying the PDSA cycle enables a structured assessment and modification of the strategies that are implemented to enhance medication labeling and packaging.

 These changes are best driven by transformational leadership. People-oriented leaders encourage change and create conditions that will enable patient safety to be embraced by everybody in the organization. They have the responsibility of creating an environment that encourages free communication and interprofessional relationships (Petersen, 2022). When a leader has a clear vision and ensures that the necessary resources are available to support the process, the transformational leader can guide the healthcare team through the process of adopting and sustaining improvements in medication management.

 Dr. Jane Thompson stated that patient safety leadership is required, and learning organizations should be encouraged. Leaders have to be involved in preventing medication errors and in changing the organizational culture so that all staff members can participate in safety improvement activities (Saltman, 1986). By applying change theory and leadership, healthcare organizations can reduce medication errors and improve patients’ care quality (Americas, 2008).

Collaboration Approaches for Improving Medication Safety

Improving medication safety is possible only when all the healthcare workers are involved in the process. Interprofessional education (IPE) is one of the strategies used in the health care system, where learners from different fields are trained and taught how to work together. IPE also promotes respect and appreciation of each other’s differences, which is very important when working in clinical areas because interprofessional collaboration is paramount (Barr, 2009).

 Another useful strategy is the use of the Team Strategies and Tools to Enhance Performance and Patient Safety or TeamSTEPPS. This evidence-based framework is centered in enhancing collaboration and cooperation amongst the healthcare givers. Through training of the staff in these techniques, healthcare facilities can promote safety and efficiency (Mach et al. , 2021).

 Also, daily interdisciplinary conferences can help to discuss medication safety concerns and encourage team members to develop a common strategy. Such a structure ensures that everyone’s input is considered, thus enhancing the development of more holistic and efficient intervention strategies (Barone, 2015).

 By using these approaches of collaboration, healthcare teams are able to increase medication safety, decrease adverse effects, and provide better care to patients.

Conclusion

It can be concluded that medication errors can be solved through better labeling and packaging to enhance patient safety in community health clinics. It is suggested that by using the standardized communication tools, new technologies and involving the patients the above mentioned mistakes can be minimized (Institute of Medicine et al. , 2007). The PDSA cycle and other change theories need to be incorporated to maintain the changes, as well as promoting transformational leadership (Petersen, 2022). Last but not least, encouraging collaboration through interprofessional education and the implementation of TeamSTEPPS improves teamwork and communication on the patient’s safety and effectiveness of care (Mach et al. , 2021). Altogether, these strategies form a strong concept that helps to prevent medication errors and enhance patients’ outcomes.

References

Al-Worafi, Y. M. (2023). Medication errors case studies: Monitoring and counseling errors. Clinical Case Studies on Medication Safety, 151-172. https://doi.org/10.1016/b978-0-323-98802-5.00021-2

Americas. (2008). National center for healthcare leadership and GE healthcare launch new institute for transformational healthcare leadership. Leadership in Health Services, 21(1). https://doi.org/10.1108/lhs.2008.21121aab.002

Apold, J., Daniels, T., & Sonneborn, M. (2006). Promoting collaboration and transparency in patient safety. The Joint Commission Journal on Quality and Patient Safety, 32(12), 672-675. https://doi.org/10.1016/s1553-7250(06)32088-0

Barr, H. (2009). Interprofessional education as an emerging concept. In Interprofessional Education (pp. 3-23). https://doi.org/10.1007/978-1-137-08028-8_1

Barone, J. E. (2015). Patient safety in surgery. Patient Safety in Surgery, 9(1), 10. https://doi.org/10.1186/s13037-014-0054-1

Berman, A. (2004). Reducing medication errors through naming, labeling, and packaging. Journal of Medical Systems, 28(1), 9-29. https://doi.org/10.1023/b:joms.0000021518.60670.10

Cohen, M. R. (2007). Causes of medication errors. In Medication Errors, 2nd Edition. https://doi.org/10.21019/9781582120928.ch4

Fewster-Thuente, L., & Velsor-Friedrich, B. (2008). Interdisciplinary collaboration for healthcare professionals. Nursing Administration Quarterly, 32(1), 40-48. https://doi.org/10.1097/01.naq.0000305946.31193.61

Hughes, R. (2008). Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality.

Institute of Medicine, Board on Health Care Services, & Committee on Identifying and Preventing Medication Errors. (2007). Preventing medication errors. National Academies Press.

Lockhart, H., & Paine, F. A. (1996). Packaging of healthcare products. In Packaging of Pharmaceuticals and Healthcare Products (pp. 188-205). Springer. https://doi.org/10.1007/978-1-4615-2125-9_10

Mach, M., Abrantes, A. C. M., & Soler, C. (2021). Teamwork in healthcare management. In Teamwork in Healthcare. https://doi.org/10.5772/intechopen.96826

Measuring medication errors. (2015). In Safety in Medication Use (pp. 86-97). https://doi.org/10.1201/b18773-14

Petersen, D. J. (2022). Transformational leadership. In Leadership in Practice. https://doi.org/10.1891/9780826149244.0007

Plan-Do-Study-Act cycle. (2004). In Encyclopedia of Health Care Management. https://doi.org/10.4135/9781412950602.n614

Saltman, R. (1986). The International Journal of Health Planning and Management, 1(2), 129-141. https://doi.org/10.1002/hpm.4740010205

Simas, D. (2022). Evaluation of causes, contributing factors, and potential solutions to medication errors. https://doi.org/10.28971/562022sd88

Turkoski, B. B. (2009). Improving patient safety by improving medication communication. Orthopaedic Nursing, 28(3), 150-152. https://doi.org/10.1097/nor.0b013e3181a50a84

Vredenburgh, A. G., & Zackowitz, I. B. (2008). Drug labeling and its impact on patient safety. PsycEXTRA Dataset. https://doi.org/10.1037/e578192012-017

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