I. Problem
a. In recent years has been a lot of focus by hospital managers to improve health care facilities since medication errors in hospitals are a serious threat to patient safety. Several studies (Carroll, 2003; Dennison, 2007; DeYoung, Vanderkooi, & Barletta, 2009) indicated that the rates of fatalities associated with medication errors in the United States were greater than 7000 deaths annually, and affected three to five percent of in-hospital patients. The ramifications of medication errors affect all healthcare organizations, resulting in consumer mistrust, increased healthcare costs, and patient injury or death (Carroll, 2003). Medication errors can occur at any stage of the dispensing and administration process but only an estimated five percent are noted in nursing documentation, suggesting that many errors that have not led to serious results are unreported (Wilkins & Shields, 2008).
II. Change Theory.
a. Many health care organizations have used Kurt Lewin’s theory to understand human behavior as it relates to change and patterns of resistance to change. Also referred to as Lewin’s Force Field Analysis, the model encompasses three distinct phases known as unfreezing, changing and refreezing (Bozak, 2003).
b. There are three stage theory of change is commonly referred to as Unfreeze, Change, Freeze (or Refreeze). This first stage of
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Communicating the Change. Communicating change should be structured and systematic. Employees are at the mercy of management to inform them of changes. When there is poor communication and the rumor mill starts spreading rumors about change, it can create resistance to the change. Being proactive in communications can minimize resistance and make employees feel like they are part of the process. Keep employees updated regularly about the plans and progress toward the change implementation. Involve all employees as much as possible through meetings or brainstorming sessions to help during the planning
Kurt Lewin was considered the father of social psychology that developed the change theory of nursing. The change theory model is beneficial for understanding when change needs to be made and prior learning to be rejected and replaced. Educating healthcare professionals with new information will help patient heath outcomes (Petiprin, 2015). (Appendix B)
Nurses were the professional group who most often reported medication errors and older patients were those most often affected in the medication errors reports analyzed for this study (Friend, 2011). Medication error type’s revealed omitted medicine or dose, wrong dose, strength or frequency and wrong documentation were the most common problems at Site A where the traditional pen and paper methods of prescription were used; and wrong documentation and omission were the most common problems associated with medication errors at Site B where the electronic MMS was introduced (Friend, 2011). Reports of problems such as wrong drug, wrong dose, strength or frequency, quantity, wrong route, wrong drug and omitted dose were less frequent at Site B (Friend, 2011). The reduced incidence of omission errors at Site B supports suggestions that an advantage of the MMS is easy identification of patient requirements at each drug round time slot. Despite the finding of less omission errors at site B where the MMS had been introduced, there was a relatively high frequency in the incident reports of medication errors related to both omission and wrong dose, strength and frequency at both sites (Friend, 2011).
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly graduated and experienced nurses. International Journal Of Nursing Practice, 18(4), 317-324. doi:10.1111/j.1440-172X.2012.02052.x
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
Furthermore, short staffing affects the quality direct care each patient receives. The National Coordinating Council for Medication Error Reporting and Prevention (2012) states an estimated 98,000 individuals die every year from medical errors in the United States. One out of many significant tasks nurses do within their scope of practice is medication administration. Research shows a relationship between short staffing on medication errors: the longer the hours nurses work, the higher the chances of medication errors (Garnett, 2008). (include definition of medication error) Administering medications requires knowledge of patient rights, pharmacological information on the drug, adverse effects, proper dosage calculations, and hospital protocols. When nurses are assigned more patients, they are pressured to give due medications on time. Sometimes due to hunger or fatigue, nurses give the wrong medication to the wrong patient (Frith, Anderson, Tseng, & Fong, 2012).
The stages of change according to the Transtheoretical Model of Change consist of precontemplation, contemplation, preparation, action, maintenance, and termination. The Transtheoretical model of change includes flexible stages. This means that an individual could be in the maintenance stage one week, relapse the next week and be back in the precontemplation stage. The stages of change are not stagnant and an individual could go up/down a stage or stages of change depending on their development of self-efficacy. Ted goes through all of these stages of change on his journey to sobriety.
Agyemang, REO, and A While. "Medication errors: types, causes and impact on nursing practice." British Journal of Nursing (BJN) 19.6 (2010): 380-385. CINAHL Plus with Full Text. EBSCO. Web. 7 Mar. 2011.
Ethical dilemmas are the issues that nurses have to encounter everyday regardless of where their workplaces are. These problems significantly impact both health care providers and patients. Patient safety is the most priority in nursing and it can be jeopardized by a slight mistake. Medication errors and reporting medication errors have been major problems in health care. Errors with medications have been found to be the most common cause of adverse drug effects (Brady, Malone, Fleming, 2009). Northwestern Memorial Hospital in Chicago conducted a research in 2012 that approximately forty percent of the hospitalized clients have encountered a medication error (Lahue et al., 2012). A nurse’s role is to identify and report these medication errors immediately in order to stop or minimize any possible harm to the patients. Ethical moral dilemmas arise when reporting the mistakes that have been made by one’s own colleagues, acquaintances, peers, or physicians.
A newly employed critical care nurse was just about to finish a 12-hour night shift when she realized she had one more patient to administer medication to. It was the busiest Friday night shift she has ever worked due to a poor nurse-patient ratio, and the workload felt impossible. She gave her last patient the properly prescribed medication, but failed to notice that the physician hastily wrote an updated dosage for a high risk medication, Digoxin. The patient’s heart rate began to slow down and life-saving procedures had to be performed. Medication errors are “any preventable event that may cause, or lead, to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer (About Medication Errors, 2015)”.
Tzeng, H., Yin, C., & Schneider, T. E. (2013). Medication Error-Related Issues In Nursing Practice. MEDSURG Nursing, 22(1), 13-50.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
Change usually comes with resistance in any workplace because change disrupts the employees’ sense of safety and control (Lewis, 2012). Kurt Lewin (1951) created a three step process for assisting employees with organizational Change (Lewis, 2012). The three stages are Unfreeze, Change and Refreeze. These are the steps to a smooth transition for change within organizations. Further, these steps are not possible without good communication from upper Management through line staff. Communication was consistently listed as an issue in surveys conducted by the department.
One of the change models of Organizational Development was created by Kurt Lewin. It includes three phases: unfreeze, move or change, and refreeze (Lewin, 1951, 1958). Lewin’s model recognizes the impormance of changing the people in organization and the role of top management involvement to overcome the resistance of change.
The first phase is introducing the change in an organization to the employee by justifying the change (Berube, 2012). Change in an organization is necessary to cope with the fast changing environment and meet the organization’s goal. The top-management is responsible to explain clearly the importance of change execute in an organization to the employee. It is necessary since there are some of experience employee is refuse to accept change and senses that change will lower their reputation and position in the working environment. As elaborated by Brown (2011), there will be criticized, ridicule and persecute in change towards any approaches used in introducing change of the organization. At this stage, la...