Medication Errors on Hospitalized Patients Discussion

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Medication errors are one of the most common causes of preventable injury to hospitalized patients. Medications that are known to pose the highest risk of harm when not used properly are known as high-alert medications. Insulin is number one of the top five medications in that classification (Adverse drug events from specific medicines | medication safety program | cdc. (2019). Hypoglycemia is a frequently seen adverse drug event caused by insulin administration and/or misuse of the medication. As defined by the American Diabetes Association (2020), severe hypoglycemia is any blood glucose reading below 54 mg/dL or any hypoglycemic event that causes an alteration in mental status and/or physical ability that requires the assistance of another person to administer treatment (Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 | Diabetes Care, 2020). This measurable, patient-centered practice problem is a quality indicator in need of improvement within my practice setting.

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My mentor is a Diabetes Care Coordinator and Educator for the hospital network. During our initial meeting, we discussed current practice protocols that are used for glucose management and he explained the data he gathers as related to harm, patient education needs and new diagnosis. The data reviewed indicated that over 90% of hypoglycemic events (glucose levels <54 mg/dL) that have occurred in 2020 have been identified as preventable. This was the deciding factor in choosing my project focus. Hypoglycemia as a quality indicator is measured in terms of rate (a percentage of occurrence in relation to number of admitted patients) which is in alignment with the American Diabetes Association recommendation (Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 | Diabetes Care, 2020).

There is a gap pertaining to relevant data availability as my mentor does not receive critical glucose values obtained through lab draws, only through point-of-care. I was told that this can not be changed. However, I feel there should be a way to gather all critical lab results though our Epic system. Another gap identified is the inconsistent implementation of nursing protocols surrounding glucose management.

Hypoglycemic events that are not part of the patient admission diagnosis interfere with the treatment plan, prolong the patient length of stay, increase facility costs and misuse valuable resources (Hh-01 Hospital Harm – Severe Hypoglycemia | Ecqi Resource Center, 2020). Through this project, I intend to develop a process improvement plan aimed at decreasing the rate of severe hypoglycemic events and improving patient outcomes.

References

Adverse drug events from specific medicines | medication safety program | cdc. (2019). Centers for Disease Control and Prevention. https://www.cdc.gov/medicationsafety/adverse-drug-events-specific-medicines.html

Diabetes care in the hospital: Standards of medical care in diabetes—2020 | diabetes care. (2020). American Diabetes Association. https://care.diabetesjournals.org/content/43/Supplement_1/S193

Hh-01 hospital harm – severe hypoglycemia | ecqi resource center. (2020). Electronic Clinical Quality Measures. https://ecqi.healthit.gov/mcw/concept/hh-01-hospital-harm-severe-hypoglycemia

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Falls are the second leading cause of death among accidental injuries worldwide. According to 2018 WHO data, as many as 646 000 persons die from falls annually, and elderly persons over the age of 65 constitute the age group with the highest incidence of fall-related deaths. (Perng, September 2019) Within my clinical setting, several areas that need improvement for the safety of patients. After discussing this project with our Safety Manager and our Home Base Primary Care RN, falls are the number one reported adverse event in the Veterans Administration Health Care System. The ultimate goal we have for our Veterans is promoting mobility and enhance the quality of life while preventing falls and, more so, falls that result in injury to veterans. (VA.gov, 2018)

Within my organization, we have a falls committee that meets to discuss all falls in or facility and Home Base Primary Care patients (HBPC) to determine cause and solution. I had the opportunity to speak with a fall committee member who is a Nurse for the HBPC team. She provides me the 2019 Fall Data Review Report. This report contained vital evidence to support falls as a safety concern for the organization. This report consisted of data breaking downfall for the last five fiscal years (FY). In FY19, 120 falls occurred within our facility. 14% was unanticipated physiological, 40% anticipated physiological, and 46% accidental. The fall Rate for 2019 was 3.35 for the organization and 4.5% at my facility. In FY19, there was a total of 312 falls in our HBPC clinic patients. The report also reported that falls being expensive; it can result in an extended hospital stay or even death, depending on the injury and the patients’ age. This report stated for FY15 estimated cost for fatal and non-fatal falls was approximately 50.0 billion dollars.

Reviewing reports and speaking with our safety Manager and Fall Committee member significantly impacted my selections of Falls for my quality improvement project. The numbers were there, and the data was present that fall was a safety problem for this organization.

Perng, H., Chiu, Y., Chung, C., Kao, S., & Chien, W. (2019, September 3). Fall and risk factors for veterans and non-veterans inpatients over the age of 65: 14 years of long-term data analysis. Retrieved October 15, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC67319…

US Department of Veterans Affairs, V. (2018, March 26). VA.gov: Veterans Affairs. Retrieved October 15, 2020, from https://www.patientsafety.va.gov/veterans/falls.as…