Ateneo de Davao University

Graduate School

Name: Dennis N. Muñoz, LPT, RM, RN Course: Nsg 707- Nursing Leadership
Student Number: 22017001253391 & Administration

Degree: Master’s in Nursing Professor: Dr. Patria V. Manalaysay

Critical Thinking Exercise - As a Change Agent

On graduation from your nursing program, you seek and obtain

employment in the local community hospital. You are assigned to the night shift.
After working for several months, you realize that there are activities that occur
among the staff at night that you believe are undesirable. For example, there has
been a practice established among some of the staff members to prepare
medications for the entire shift and place the (with labels) in a cupboard for quick
access.

You believe this is unsafe. You would like to change this practice. How would you
proceed?

Answer:

My essay today begins with the two definition of terms:

1. Errors are failures of planned actions to be completed as intended, or the use of

wrong plans to achieve what is intended.
2. Adverse events are injuries caused by medical intervention, as opposed to the
health condition of a patient. A large proportion of adverse events are the result of
errors. When the adverse event is the result of an error, it is considered
a preventable adverse event.

Medication errors are the most identified errors occurring in every healthcare setting.
The consequence of this negligence is the potential to cause death to a patient or
increase hospital length of stay and many of these errors deemed preventable. If I were
a nurse in a new assignment, the knowledge I acquired in the school is still fresh, the
idealistic view of standard practice is still my vanguard against malpractice. Since I
imbibed with the principles of nursing of what is right and what is ought to do, the
domain characteristics as a changed agent, I consider the situation as a big part of the
challenge in adapting the practices to fit a clinic's environment against those who
already honed to the tradition and culture in the health facility.

In the book entitled: To Err is Human: Building a Safer Health System published in 2000
by International Organization for Migration or IOM, Medication errors are often
preventable, although reducing the error rate significantly will require multiple
interventions. In the study of prescribing errors conducted by Lesar et al., the most
common factors associated with errors were decline in renal or hepatic function
requiring alteration of drug therapy (13.9 percent); patient history of allergy to the same
medication class (12.1 percent); using the wrong drug name, dosage form, or
abbreviation (11.4 percent for both brand name and generic name orders); incorrect
dosage calculations (11.1 percent); and atypical or unusual and critical dosage
frequency considerations (10.8 percent). The most common groups of factors
associated with errors were those related to knowledge and the application of
knowledge regarding drug therapy (30 percent); knowledge and use of knowledge
regarding patient factors that affect drug therapy (29.2 percent); use of calculations,
decimal points, or unit and rate expression factors (17.5 percent); and nomenclature—
for example incorrect drug name, dosage form, or abbreviations (13.4 percent).

According to Luciano (2019) "Leaders have to balance two conflicting needs: to adhere
to standards and to customize for the local context," they write. "Attempting to simply
'plugin' a new practice to a different hospital or clinic often conflicts with existing
practices but deviating from the evidence-base can weaken the effectiveness of the
practice and lessen the benefits.”

This means, for nurses in the ward to succeed in a medication error-free their work, it is
crucial for them to understand what procedures are most supported by research-based
evidence and to continue learning as these conclusions change. Evidence-based
practice is vital for nurses seeking to improve in a professional nursing career. Adopting
EBP in the culture of practice improves patient outcomes and patient, family, and
healthcare provider satisfaction. It can also reduce costs and the risk of harm, therefore
Best practices are the backbone of effective nursing

Proactive planning is so far an effective way of dealing with this problem. This means
designing a desired future while inventing ways to create that future state. Not only is
the future a preferred state, but also the organization which includes all staff nurses on
duty at the lower level can actively control the outcome and that safe nursing practice is
executed without conflict interest to one another.

Planners actively shape the future, rather than just trying to get ahead of events outside
of their control (Wirth, 2010). In my perspective with this type of planning, it has a
tedious preparation with a high degree of accountability. I see these two, proactive
planning and EPB as intangible parts in the evaluation of the quality of care since one of
the main responsibilities in the execution of the nursing profession is to uphold the
standards for safe nursing practice according to RA 7392 or the Nursing Practice Act
2002. It is just right to be mindful and sensitive in every action initiated to ensure the
preservation of life because the quantity of tasks comes with quality therefore things
should be handled with great care. In General, EBP allows healthcare professionals to
develop best practices in the floor (wards) using educated published materials, reduce
variation in treatment, increases nurses’ ability to provide safe and effective services,
improves patient outcomes, decreases costs for patients and institutions by
standardizing and streamlining care, decreases the likelihood of unnecessary
procedures, reduces the chance of complications, encourages efficient decision making,
and promotes continual learning (Husson University, 2019).

Effective Proactive Planning and evidence-based practice are correlative with each
other, thus: According to District Multi-Sectoral AIDS Committee (DMSAC) Planning
Toolkit 2008 in Botswana, Evidence-based means that the best available data,
information, and knowledge are used to make decisions. Therefore, evidence-based
planning is harnessing the knowledge gained from data and information and using it to
optimize our planning process and improve results. What impressive result are we
waiting for? Of course, it is the low quantity of medication error.

I have collected some of the evidenced-based practices including strategies derived

from the works of Vickerie in 2018 on how to effectively control and provide
precautionary measures against medication:

1. Ensure the 10 rights of medication administration (Kee & Lefevre, 2018).

Nurses must ensure that institutional policies related to medication transcription are
followed. It isn’t adequate to transcribe the medication as prescribed, but to ensure the
correct medication is prescribed for the correct patient, in the correct dosage, via the
correct route, time and frequency, documentation, assessment, refuse, Drug-Drug
Interaction and Evaluation, and Education and Information.

2. Follow proper medication reconciliation procedures.

Institutions must have mechanisms in place for medication reconciliation when

transferring a patient from one institution to the next or from one unit to the next in the
same institution. Review and verify each medication for the correct patient, correct
medication, correct dosage, the correct route, and correct time against the transfer
orders, or medications listed on the transfer documents. Nurses must compare this to
the medication administration record (MAR). Often not all elements of a medication
record are available for easy verification, but it is of paramount importance to verify with
every possible source—including the discharging or transferring institution/unit, the
patient or patient’s family, and physician—to prevent potential errors related to improper
reconciliation. There are several forms of medication reconciliation available from
various vendors.

3. Double-check—or even triple check—procedures.

This is a process whereby another nurse on the same shift or an incoming shift reviews
all new orders to ensure each patient’s order is noted and transcribed correctly on the
physician’s order and the medication administration record (MAR) or the treatment
administration record. Some institutions have a chart flag process in place to highlight
charts with new orders that require order verification.
4. Have the physician (or another nurse) read it back.

This is a process whereby a nurse reads back an order to the prescribing physician to
ensure the ordered medication is transcribed correctly. This process can also be carried
out from one nurse to the next whereby a nurse reads back an order transcribed to the
physician’s order form to another nurse as the MAR is reviewed to ensure accuracy.

5. Consider using a name alert.

Some institutions use name alerts to prevent similar-sounding patient names from
potential medication mix up. Names such as Johnson and Johnston can lead to easy
confusion on the part of nursing staff, so it is for this reason that name alerts posted in
front of the MAR can prevent medication errors.

6. Place a zero in front of the decimal point.

A dosage of 0.25mg can easily be construed as 25mg without the zero in front of the
decimal point, and this can result in an adverse outcome for a patient.

7. Document everything.

This includes proper medication labeling, legible documentation, or proper recording of

administered medication. A lack of proper documentation for any medication can result
in an error. For example, a nurse forgetting to document an as-needed medication can
result in another dosage being administered by another nurse since no documentation
denoting previous administration exists. Reading the prescription label and expiration
date of the medication is also another best practice. A correct medication can have an
incorrect label or vice versa, and this can also lead to a med error.

8. Ensure proper storage of medications for proper efficacy.

Medications that should be refrigerated must be kept refrigerated to maintain efficacy,

and similarly, medications that should be kept at room temperature should be stored
accordingly. Most biologicals require refrigeration, and if a multidose vial is used, it must
be labeled to ensure it is not used beyond its expiration date from the date it was
opened.

9. Learn your institution’s medication administration policies, regulations, and

guidelines.

For nurses to follow an institution’s medication policy, they must become familiar with
the content of the policy. This is where education comes into play whereby the
institution’s educator or education department educates nurses on the content of their
medication policy. These policies often contain vital information regarding the
institution’s practices on medication ordering, transcription, administration, and
documentation. Nurses can also familiarize themselves with guidelines such as the
Beers’ list, black box warning labels, and look-alike/sound-alike medication lists.

10. Consider having a drug guide available at all times.

Whether it’s print or electronic is a matter of personal (or institutional) preference, but
both are equally valuable in providing important information on most categories of
medication, including trade and generic names, therapeutic class, drug-to-drug
interactions, dosing, nursing considerations, side effects/adverse reactions, and drug
cautionary such as “do not crush, or give with meals.”

Utilizing any or all of the above strategies can help to prevent or reduce medication
errors. Nurses must never cease to remember that a medication error can lead to a fatal
outcome and it is for this reason that med safety matters.

What steps would you take?

Answer:

It is important to understand not only how the medication is used under normal/routine
settings, but how the workflows and environment change under stressful or challenging
conditions. How the different users adapt to change often provides a catalyst for
medication errors and near misses. It is important to remain unbiased and unobtrusive
to gain a true understanding of medication use. A thorough assessment will yield a
wealth of knowledge that can be used to inform the design of new medications or
medication safety interventions.

Two very different views are often held about why errors in health care, like errors in
other industries, occur (Reason, 2000).

The first view holds individuals as primarily responsible for any error or unsafe action.
Unsafe acts are viewed as arising principally from an individual's faulty mental
processes or weaknesses of character, such as forgetfulness, inattention, poor
motivation, carelessness, negligence, and recklessness. Bad outcomes are viewed
largely as the result of bad behavior by people, behavior that should be corrected
through workplace policies and procedures, safety campaigns, disciplinary measures,
the threat of litigation, retraining, and “naming, blaming, and shaming.” In this view,
when workplace errors occur, the person most directly involved in the work at the time
the error is thought to have taken place (often known as “the last person to touch the
patient”) might well be blamed.

The second view is contrasting systems view of errors and error prevention is based on
research findings from a variety of fields, including studies of accidents and breaches of
safety in a variety of industries, studies of “high-reliability organizations,” and research
into effective organizational and managerial practices. In all of this work, the
interdependent interaction of multiple human and nonhuman (equipment, technologies,
policies, and procedures) elements of any effort to achieve a stated purpose is regarded
as a “production process” or “system.” These interrelated human and nonhuman system
elements are required to operate in synchrony if a given goal is to be achieved. As the
elements of the production process or system are changed, the likelihood of error also
changes. This research has revealed that errors typically result from problems within the
system in which people work—not from poor individual worker performance—and
typically originate in multiple areas within and external to an organization. Error results
when these multiple problems converge and impair an organization's performance
(Perrow, 1984; Reason, 2000).

What would you need to consider?

Answer:
In the seminal book Patient Safety and Quality an Evidence-Based Handbook for
Nurses by Hughes (2008) “Effective clinical practice thus involves many instances
where critical information must be accurately communicated. Team collaboration is
essential. When health care professionals are not communicating effectively, patient
safety is at risk for several reasons: lack of critical information, misinterpretation of
information, unclear orders over the telephone, and overlooked changes in status, thus
lack of communication creates situations where medical errors can occur.”

Collaboration in health care is defined as health care professionals assuming

complementary roles and cooperatively working together, sharing responsibility for
problem-solving, and making decisions to formulate and carry out plans for patient care
(Fagin, 1992).

Through effective Teamwork, it becomes an avenue for each member to be more open
to communication with being judgmental and biases toward the suggestions offered by
the member. It interplays smooth interpersonal relations while sharing ideas with best
practices with a successful outcome in a nonpunitive environment. This is because it will
lessen the threatening nature of the personality of the nurse against each other to adapt
to the new guidelines and to ensure safe nursing practice in handling medicine. A Clear
direction such as team buildings and short meeting or a corkboard reminder can help
each other to be responsible and self-directive. Clear and known roles and tasks for
team members must be well defined into his or her job description thus it helps
minimized overlapping of the task and responsibilities. A Respectful atmosphere helps
reduce tension in the flor (ward) into friendly working and learning environmental
conditions while building shared responsibility for team success. Other important
consideration includes an appropriate balance of member participation for the task at
hand, acknowledgment, and processing of conflict, clear specifications regarding
authority and accountability, clear and known decision-making procedures, regular and
routine communication and information sharing, enabling environment, including access
to needed resources and the team must create a mechanism to evaluate outcomes and
adjust accordingly.
Of the theories and strategies discussed, which one(s) might work best?

Because many best strategies and practices will work, no single model for leadership
and management is available to support all the problems and issues that arise in the
health care setting. In my understanding, all might work because each theory has its
strength or advantages, in contrast, it has disadvantages well. When a particular theory
is applied For example in the Scientific management by Fayol, let say Managers must
provide detail instruction and supervision to ensure the job is done scientifically, thus
the focus of the theory is to ensure systematic, direct reward-based mechanism, and
productivity is timed and equal to quality at an individual level as per designation on
individual tasks to work level. However, a drawback arises because, although it helps
improve the quality of services it cannot be applied best to the group or team level. I
shall say all may be possible as a guidepost to our daily work activity, let us remember
they are theories to help guide and give direction to our task but the meaning of that
task is best appreciated by the doer himself.

As a change agent, words alone are an ineffective leadership tool. Leadership

commitment must be expressed through actions observable to employees (Carnino,
undated; Spath, 2000). Leadership actions that management can take include the
following:

1. Undergoing formal training to gain an understanding of safety culture concepts and

practices
2. Ensuring that safety is addressed as a priority in the strategic plans of the
organization
3. Having facility-wide patient safety policies and procedures that delineate clear plans
for supervisor responsibility and accountability and enable each employee to explain
how his or her performance affects patient safety
4. Regularly reviewing the safety policies of the organization to ensure their adequacy
for current and anticipated circumstances
5. Including safety as a priority item on the agenda for meetings
6. Encouraging employees to have a questioning attitude on safety issues
7. Having personal objectives for directly improving aspects of safety in managers'
areas of responsibility
8. Monitoring safety trends to ensure that safety objectives are being achieved
9. Taking a genuine interest in safety improvements and recognizing those who
achieve them—not restricting interest to situations in which there is a safety problem
10. Reviewing the safety status of the organization on a periodic (e.g., yearly) basis and
identifying short- and long-term safety objectives
11. Finally, leadership's commitment to safety is evidenced by a willingness to direct
resources for improved safety, as reflected in the organization's budget

Above all, nurses must be vigilant for the possibility of medication errors in the health
care setting, recognizing the associated risk factors. Technology provides many
opportunities to improve communication with fellow nurses, to provide the staff with
accurate information, to educate about mechanics of correct medication administration,
and to monitor medication regimes. Paying close attention to potential risk is most
effective; therefore, accurate documentation and review of medications during each
encounter is important. The evidence suggests that frequent medication reviews and
collaboration with other members of the health care team, especially pharmacists, will
help to prevent adverse events associated with poor medication management.

References
1. Evidence-based practice in a clinical setting. (2020, May 27). Nurse.com digital
guides and publications. https://resources.nurse.com/evidence-based-practice-
clinical-setting-nnw
2. Fagin, C. M. (1992). Collaboration between nurses and physicians. Academic
Medicine, 67(5), 295-303. https://doi.org/10.1097/00001888-199205000-00002
3. Intro to evidence based practice. (2017, June 5). Husson
University. https://online.husson.edu/evidence-based-practice/
4. Luciano, M. (2019). 4 ways to implement evidence-based practice at your hospital.
Advisory Board. https://www.advisory.com/daily-briefing/2019/09/10/evidence-
based-practice
5. The mid-term review of the Botswana national strategic framework for HIV/AIDS,
2003-2009.
(2008). https://www.nastad.org/sites/default/files/NASTAD_Botswana_Evidence_Ba
sed_Planning_Toolkit.pdf
6. The national academies - Keeping patients safe - NCBI bookshelf. (2004). National
Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK216184/
7. The national academies - To err is human - NCBI bookshelf. (2000). National Center
for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK225173/
8. O’Daniel, M., Rosenstein., A. H., & Hughes, R. G. (2008). Professional
communication and team collaboration - Patient safety and quality - NCBI bookshelf.
National Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK2637/
9. Vickerie, D. (2018). 10 strategies for preventing medication errors. Minority
Nurse. https://minoritynurse.com/10-strategies-for-preventing-medication-errors/
10. Wirth, R. A. (2010, February 16). Approaches to planning - a workshop
activity. enTarga Business Planning - Leading Strategic Organizational
Change. https://www.entarga.com/stratplan/activity01.htm