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Medication errors can occur in any setting. Much has been done to eliminate this problem, yet there is much more than need be done to provide safe patient care. If I were asked to gather an interprofessional collaborative (IPC) team, in response to a recurring medication error and to prevent future mistakes in the inpatient medical-surgical unit where I work, I would put together a team from different disciplines within the institution. I would gather an IPC team to include members who can contribute to the solution, have expert advice, and who can help lead the change in a quality improvement project. According to Dang and Dearholt, (2018), the IPC team should be precise enough to be effective, yet large enough to have expert knowledge of the presenting problem. The IPC team would include a pharmacist, nurse educator, nursing manager, unit head nurse, a registered nurse, a physician, an informatics specialist, and a practicing scholar.
The responsibilities of each team member begin by the team coming together, and being prepared to share evidence-based content to help resolve the practice problem. For a team to be effective, the members of that team need to be able to share and understand each other roles (Etherington et al 2019). The role of the IPC members is to understand the impact the practice problem has on patients’ outcome, staff morals, and healthcare cost and to research ways to solve the problem. Members need to be knowledgeable about the topic presented. The team should be committed to the project and should be motivated to resolve the practice focus problem. I would have weekly meetings with team members to follow up and feedback.
Medication errors are listed under patient safety, which is one of the eighth practice problem burden in the United States of America (Chamberlain College of Nursing 2020). According to the World Health Organization (WHO), a medication error can occur during any step of the medication process, from prescribing to administering (2016). Therefore, the team should be looking into all potential medication error aspect. The team leader should distribute tasks accordingly, and hold each team member accountable for the task assigned. The team of ICP shall strategize a plan to prevent medication errors in the unit.
The nurse researcher and educator would establish policies, protocols, and training modules for unit nursing staff. The Informatics specialist will review the current technology and improve the system to identify and create alert as soon as a medication is written by the prescriber. The pharmacist would work within it department to establish a clear protocol for requesting clarification before any questionable medication is dispensed to the unit. The nurse manager and unit team will work on reeducating the staff on safe medication administration. Nursing leaders need to create a culture of confidence among staff, that it is appropriate to question a provider’s order if deemed unsafe. In a pilot study by Boscart et al., (2017) they found that interprofessional teamwork, education, and open communication promote best practice and improve quality of care in heart failure patients in a long-term care setting. I believe respectful communication among disciplines is beneficial in all clinical practices.
It is well known, that there is no I in team. For a team to be successful it members have to be able to work well alongside each other. Mutual respect for each other opinions is a must for the team to succeed. Ineffective communicating is the root cause of misunderstanding. It happens in personal relationships, boardrooms, and of course in healthcare settings. Often, the failure to communicate can have life-changing impacts of patients, family, nurses, insurances providers and healthcare systems. Clapper (2018) indicated that debriefing allows team members time to critique performance and discuss ways for improvement. To facilitate effective communication and collaboration, there should be frequent feedback from team members.
Boscart V.M., Heckman, G.A., Huson, K., Brohman, L., Harkness, K.I., Hirdes, J., McKelvie, R.S., & Stolee, P. (2017) Implementation of an interprofessional communication and collaboration intervention to improve care and capacity for heart failure management in long-term care. Journal of Interprofessional Care. 31 (5), 583-592. Doi.org/10.1080/13561820.2017.1340875
Chamberlain College of Nursing (2020) NR-701 Week 1: Application of Analytic Methods (Online Lesson) Adtalem Global Education
Clapper, T (2018). TeamSTEPPS is an effective tool to level the hierarchy in healthcare communication by empowering all stakeholders. Journal of Communication in Healthcare 11 (4) 241-244. Doi.org/10.1080/17538068.2018.1561806
Dang, D., & Dearholt, S. (2018) John Hopkins nursing evidence-based practice model and guidelines (3rd ed.). Sigma Tetu Tau Intentional.
Etherington N., Wu M., Cheng-Boivin O., Larrigan S., Boet S. (2019) Interprofessional communication in the operating room: a narrative review to advance research and practice Canadian Journal of Anesthesia 66 (10) 1251-1260 doi.org/10.1007/s12630-019-01413-9
Medication Errors. Technical series on safer primary care. (2016) World Health Organization. License: CC BY-NC-SA 3.0 IGO. www.WHO.org
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