The problem of medical errors and how they impact the health of the patients who are
affected is a worldwide issue. An incident involving a medication error can cause long lasting
effects. Patients may experience terrible side effects, develop more severe health complications
or die from the experience. Preventing medical errors, especially those that involve medications
are of the utmost priority in all health care facilities. While not all medical errors are drug
related, those that do involve medications can almost all be prevented if the right precautions and
solutions are found and implemented.
Once the problem has been identified, the next step is to develop a viable solution that
will meet the needs of the facility, be easy to use and understand while improving the safety of
the patients. While this seems like a lot to accomplish, it can be done with the right resources and
plan of action. When developing a solution to an existing problem, the first step is to talk to
those who must deal with the problem on a daily basis and get their input on what they feel is
most important in creating a solution. Interview and surveys are excellent ways to get initial
feedback when trying to put together a plan of action for the future.
Designing and developing a working system relies on the input of all involved. The
physician, pharmacist, nurse and even the patient can all provide valuable view points into the
effectiveness and convenience of such an elaborate system. With all of the data gathered,
building the system is the next step. As it begins to develop and take shape, implementing it on a
trial basis may provide insight as to glitches and bugs that may need to be worked out before the
system can be put into action at full speed. Constantly evaluating, adjusting and observing how
the system operates is a good clue as to successful it will be in the long run.
Constantly gathering data and evaluating the system will ensure it stays on the right
track as it pursues its many objectives. If at any time, failure begins to appear on the horizon, the
managers of the facility and those who use it regularly must step in to try and correct the problem
or remove the system from service and find a more effective way to accomplish the company’s
goals. Great care must be taken when choosing to eliminate an existing system. Not all parts of
the project may have to be eliminated. Careful consideration must be given to each aspect of the
project and the benefits it offers as well as any possible negatives that will influence its outcome.
Communication on all levels is vitally important and must be maintained to ensure the
system remains viable and continues to do the job it was designed for. Evaluating information
received in the form of surveys or feedback will help support data retrieved from files and
documentation. Reviewing all aspects of the information can prevent major problems from
occurring that could spell the end of the project. If problems arise and are caught early enough,
feedback from both the users of the system and the developers could help restore the program
and make it better than it was originally. Continued communication enhances and protects the
investment each person puts into a project of this size and nature.
Section A: Problem Identification
Errors that occur in the health care profession impact a person’s health and also their
quality of life. In some cases, it may mean the difference between life and death. In the medical
field there are two main types of errors. The first is mechanical error when a piece of machinery
or equipment malfunctions or breaks down due to a defect or wear and tear. While some
mechanical errors may be attributed to the individual who operates them, others occur because of
The second type of error is human error. It is the most obvious and sometimes the most
dangerous of the two types. It can be as simple as the transposition of number when prescribing
medication or as complex as nicking a major artery during an organ transplant surgery. No
matter how large or small the error is, human error can be prevented. Diligence and close
monitoring of every aspect of a physician’s, nurse’s or other healthcare professional’s activities
can help prevent human error and reduce the impact they have on a patient’s care. Both types of
error drastically impact a patient and should be avoided at all cost.
It is estimated that anywhere from 44,000 to 98,000 hospitalized patients die each year
because of a medical error. Deaths attributed to errors that have to do with medications account
for over 7,000 deaths each year. Comparing even the lowest set of estimated numbers, it is
believed medical errors kill more people each year than both breast cancer and automobile
accidents (“Medical,” 2013).
Studies are performed each year in an attempt to discover the impact of medical errors on
patient care and quality of life. While many believe the studies are subjective, they do offer proof
that medical errors do have a direct impact on the number of deaths involving hospital patients
each year. A studies ability to monitor and correlate the number of deaths in comparison to the
number and frequency of medical errors is one way of determining if the two are related in any
One of the goals of the project is to reduce the number of medical errors involving
medications by at least 50 percent. In the following proposal we suggest as part of the solution to
the problem is the addition of a bar code and scanning system. While this is already in place in
certain areas, it can be expanded to include bar codes on all objects relevant to the patient’s care,
including their charts, medication bottles, wrist bands and any other device or product used in
Scanning devices can be placed in a patient’s room so that a nurse or physician can scan
the medication or other object to ensure it matches up with the patient’s scanned bracelet and
chart and to assist with the process of documenting. If it does not match up correctly, proper
measures must be taken to determine what is wrong and how the problem presented itself. If all
scans match and no discrepancies are found the medication can be dispensed as written and
Section B: Solution Description
The proposed solution would entail assigning a scanner to each patient with that scanner
being calibrated to a bar code on the patient’s bracelet, chart and room placard. Bar codes would
be attached to what ever medications a patient is scheduled to receive. Any orders attached to
their chart would also have the patient’s bar code. While tools and instruments used on all
patients, such as electronic thermometers, blood pressure cuffs and stethoscopes could still be
used on several patients, instruments relating to a patient’s specific condition would remain in
their rooms and be labeled with their personal bar code.
This solution is consistent with recent findings, indicating cross checking medications to
patient bracelet and charts is an effective way of reducing the risk of errors made that involve
medications. Current research also supports the use of electronic tracking as a way of effective
monitoring and recording the delivery of medication. It also is an accurate tool when recording
the results and impact of various procedures performed on the patient (Hook, Pearlstein,
Samarth, and Cusack, 2008).
Facilities already using scanning systems when dispensing medications have reported a
dramatic decrease in drug related medical errors. The National Institute of Health has published
several papers on the subject and states the reduction of such errors which occurred during
hospital med passes and during surgery has dropped significantly since the scanning technology
has become available. Establishing a method of electronically monitoring the entire medication
process from the point of prescription to the resulting dispensing of the medication would also
help to prevent mistakes. Allergies, recalls and other important information would be included in
the charting and documenting process, eliminating almost all possibilities of error (Agrawal,
The feasibility of implementing the scanners and broadening their use to include
procedures is a distinct possibility that offers positive benefits. By broadening the scope of their
use, nurses and physicians alike would be able to continually monitor all aspects of a patient’s
continued care. Advances in technology would make using the system convenient and efficient
to use. Medications could be closely monitored and the data received could help with the
charting process. An exact dosage could be dispensed and recorded without errors occurring
from the nurse or physician mistakenly writing down a wrong number or amount. The system
would also dramatically reduce the risk of the wrong medication being given to the wrong
patient (Andel, Davidow, Hollander, and Moreno, 2012).
The proposed solution is consistent with measures already in place involving the
handling and dispensing of medications. Physicians take special care when prescribing a
medication, avoiding possible allergens and contraindications. Pharmacists double check for
accuracy when filling prescriptions to avoid recalls and allergies a physician may have missed.
Nurses manually check medications as they are being dispensed. Those who have scanner
systems use both methods to reduce the risk of medical errors involving medications. The
solution would include additional scan points in the process as well as enable the nurse to
document each med pass through the scanning system. By including the scanning technology in
the process from beginning to end would greatly reduce errors and limit the possibility of a
Section C: Research Support
The research base developed to determine the feasibility of implementing a scan system
that begins with the physician entering the prescription to the patient receiving the medication is
four fold. First would be the introduction of the system with components being placed with
physicians, pharmacists, nurses and patients. Once it is assured that everyone understands how
the system works, the evaluation process would begin. Two groups would be formed. One would
use the scanner system exclusively while the other would rely on manual checks and balances.
The efficiency of the system would be closely monitored once the information is entered
into the system and thoroughly documented. Bar codes would be assigned to medications that
would identify who they are prescribed to, dosage, times to be given, etc. Once identifiers are in
place, the scanners would be used to track where the medications were sent, how they were
dispensed and documentation would be entered storing all pertinent information. The second
group would monitor all steps of the medication dispensing process from beginning to end
without the benefit of IT/scanning technology.
At the end of specific amount of time, (six months to 1 year depending on the number of
participants and the location), the number of errors would be calculated along with any financial
costs of correcting or treating any adverse reactions from the event. All of a patient’s medical
expenses would be reviewed as well as any documentation and treatment plans to make sure all
medications prescribed played viable roles in the improved health of the patient. Any incidence
of unnecessary medication being prescribed to a patient would be considered an error on the part
of the primary care physician. Over-medicating is considered to be a medical error and can cost
insurance and other healthcare providers thousands of extra dollars each year, not to mention the
additional health problems they can lead to.
The internal findings of the research would be compared to findings of other studies to
determine if the results were consistent. Similar studies such as those performed by external
agencies like the Agency for Healthcare and Research Quality, the Quality Interagency
Coordination Task Force and the United States Federal Food and Drug Administration would all
be reviewed and compared to the internal results. By comparing the internal findings to the those
from other studies performed by external organizations and medical agencies, a broad range of
information could be covered giving an accurate view of how IT/scanning technologies can
improve patient care (Shalala, and Herman, 2000).
The FDA’s studies revolved around the labeling of medications and tracking systems
used to monitor how each drug was dispensed. Bar codes were used along with an automated
scanning system that helped physicians and nurses keep track of all medications that were being
dispensed (‘Strategies,” 2011). The AHRQ and QuIC Task Force have performed several studies
each using a variety of methods to track medications and how they are dispensed. All of three of
the organizations showed dramatic improvement when scanning and other automated systems
were employed to track medications. Even when the tracking system was in place for only part
of the process, the occurrence of medication errors was dramatically reduced.
Section D: Implementation Plan
Implementing the proposed solution would involve getting approval of board members at
the facility in which the solution was to be used. Physicians, pharmacists, nurses and other
healthcare providers must all be willing to participate in the project to determine its viability and
prove its overall effectiveness. Incentives can be offered to staff members who participate fully
in the program and strive to ensure its success.
Funding for the extra equipment may need to be purchased. Using financial resources
such as municipal bonds and grants from drug companies such as Eli Lily are options that can be
considered. IT companies that specialize in the design of software and tracking programs that
use bar codes and other electronic tagging systems may also offer financial assistance in
purchasing the tools needed to implement the system.
Application for funding through municipal bonds and grants can take several months and
must be voted on within the community and by the board of directors of large corporations. Once
the funding has been approved, the implementation process can begin to move forward.
Preparing staff members within the hospital or nursing facility is an important part of the process.
Monitoring the implementation process and providing all staff members are instructed in
how to correctly use the new system is vital to making sure everything is set up properly and will
be effective. In the first few months of the implementation of the new program, constant
feedback between staff members and the IT crew will help work out any bugs within the system.
Daily and weekly checks should be performed to catch any discrepancies. Manual monitoring of
all documentation should remain in effect until it is assured the system is in good working order
and everything is being captured accurately.
Theorizing the steps needed to plan for changes within the system means dividing the
process into sections which can be monitored and evaluated. Dividing the process up into
manageable time frames, each phase in the implementation process can be complete and
operational before the next one begins. This gives enough time for each phase to be evaluated
and changes to be in place before the next phase is started. It also provides ample training time
for staff members to become accustomed to using the new system. As the training process
continues, each phase is reviewed and new information is added so staff members have a
continual learning experience and all phases are taught and understood as parts of the same
Planning each phase and implementing them one at a time, in a specific order will help
staff members become accustomed to the new processes. As each phase is established, staff
members should evaluate the processes to determine if any changes or adjustments should be
made. Feedback would then be presented to the IT or technical advisers so corrections can be
made. The feasibility of the implementation plan is viable as long as all members of the staff do
their part in reporting changes, adjustments and positive feedback.
Section E: Evaluation Plan
Computer generated audit trails and time/date stamps are just two of the methods that can
be employed to evaluate how well the proposed solution is working. Manual review is also an
important method of verifying and checking various aspects of information. Reviewing
documented information by both electronic and manual methods will allow researchers to
determine just how well the system is functioning and where possible problems may arise as the
program continues to operate.
Situations/Priorities = Inputs
Outcomes and Impacts
Using situations and priorities along with inputs that include accurate documentation and
information gained throughout the study and implementation of the program, conclusions can be
formed as to how well the solution is working. Output of information that consists of activities
and lists of people who participated in the program will lead to the resulting outcomes and
impacts of the implementation of the proposed solution.
Outcomes are measured by the success of training programs, the delivery of information
and the developing of new programs. Staff, volunteers and funding are put into the program in an
attempt to help participants produce effective results. All goals, short, medium and long term, are
evaluated and reviewed to determine whether the proposed solution was a success or if changes
need to be made. Each method of evaluation will have a distinct impact on how viable the
information is. Information that is time sensitive will be best evaluated using the time/date
stamping method to ensure accuracy (“Outcome”).
Evaluation Data Collection
Observation, interviews, surveys and documentation review are the most common ways
of collecting data. Patient records, both electronically stored and handwritten charts provide vital
information as to how well a program or proposed solution has performed. While surveys are
beneficial, observation and interviews will help to answer questions that can’t be answered by
numbers alone. Records and other forms of documentation offer the most accurate and concise
forms of data that is easily evaluated and compiled.
Using all four methods of data collection is an effective way to gather and evaluate all
types of information. With all four types of information collected a complete view of the
progress of the program and how well the system is functioning. Records and documents provide
the foundation, while the other three forms of data fills in any gaps that may appear in the mix.
Incorporating all types of data will help present the “big picture” to investors and researchers
who have a stake in how well the solution works.
Eli Lily and QualCom are two possible resources that may provide grant funding to put
the proposed solution into action. Eli Lily’s role was one of the lead drug manufacturers in the
world puts them in a respected position to protect the individuals who rely on their medications
from medication errors. Eli Lily has been in business for over 135 years. They have made their
mark by producing medications and drugs that have saved the lives of millions of individuals
who, without their medications would have possibly died due to complications of their illnesses.
Eli Lily has dedicated itself to ensuring the individuals who rely on their medications can do so
without fear of harm. This includes while they are in a hospital setting. Applying for grant
resources through Eli Lily’s many endowment programs would be a positive way for the
company to influence change and promote a safer environment for their patients (“About,” 2013).
QualComm is a leader in the IT field when it comes to networking and data usage and
collection. They have vital resources available to them that could help fund a program such as
the solution in this proposal. With their expertise and knowledge when it comes to tracking
information and designing effective operating system, QualComm is the company to look to for
both funding and technical advice when it comes to implementing a system to track medication
errors (“Wireless health,” 2013).
Section F: Decision Making
Using analytical data, feedback and information gained from normal record keeping
procedures are affective ways for projecting the successful future of the proposed solution.
Feedback provided by the individuals who work with the project can advise developers of the
proposed solution is fulfilling the objectives it was designed to accomplish. Evaluating the
overall effectiveness of the system and comparing the data with feedback from individuals who
use the system on a daily basis will help to form a reasonable opinion of how well the system
Frequent evaluation and review of the information and statistics provided from the
system itself and making continual adjustments as they are needed will assist the company in
furthering the progress of the proposed solution in all of its several phases, from inception to
completion. Extending the goals of the company forward and providing the necessary tools to
maintain the system’s progress is essential for the continued success of the project solution.
If at any time, the system shows signs of failure, a review should be conducted to
determine the extent of the negative impact the solution is having on patients and workers at the
facility. For a project that is designed to prevent errors involving the dispensing of medication,
even a small failure is unacceptable. At no time, should a project be allowed to continue if there
is any chance or risk of patients and staff members facing adverse reactions due to the
negligence or error of someone who is in charge of dispensing medications or documenting
information about a procedure or treatment plan.
When it becomes apparent that a system is failing or mistakes are occurring and going
undetected by a system that was designed solely to prevent them, the entire project should be
terminated. If certain areas of the solution appear to be functioning correctly, they may be left in
place as long as they are able to stand alone without the rest of the system influencing it.
Shutting down an failing system requires data and information to be backed up on separate files
and stored in such a way that all of the information remains intact and available for future use.
The system can be eliminated one section at a time, in basically the same way it was
implemented. This allows all vital information to be preserved so it remains viable and
accessible to staff members who may need it.
A list of contacts should be created and distributed to groups outside of the facility to
keep them abreast of what is going on with the new system. Investors, grantors and IT
professionals may request feedback on how the system is functioning and what impact
adjustments have had on the system as a whole. A protocol should be in place so companies who
have a vested interest in to eh proposed project and solution can call and inquire on its status. By
keeping with this protocol, people who are interested in a specific area or project can call the
same person each time instead of talking to various people who may have no knowledge of the
project or its objectives.
Communication between staff members, investors, management and IT professionals
must be concise and to the point, relaying vital information. All individuals involved with the
process must be kept up to speed in case an event or incident arises where immediate action
needs to be taken. Correcting mistakes as they happen may help to prevent larger issues in the
future that could jeopardize the successful outcome of the program as a whole (Argenti, Howell,
and Beck, 2005)
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