Capella University Medication Errors Research Paper

Write a 4-6 page analysis of a current problem or issue in health care, including a proposed solution and possible ethical implications.


In your health care career, you will be confronted with many problems that demand a solution. By using research skills, you can learn what others are doing and saying about similar problems. Then, you can analyze the problem and the people and systems it affects. You can also examine potential solutions and their ramifications. This assessment allows you to practice this approach with a real-world problem.


Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum, be sure to address each point. In addition, you are encouraged to review the performance-level descriptions for each criterion to see how your work will be assessed.

Describe the health care problem or issue you selected for use in Assessment 2 (from the

Assessment Topic Areas

media piece) and provide details about it.


Assessment topic areaIntroductionSelecting a topic for your written assessments can be challenging, but it’s important to make a thoughtful choice.Choose a topic area of interest to you from the topic suggestions in this media piece. You will use this topic to complete Assessments 2 and 3. Be sure to select a topic that will be manageable for a written assessment.To explore the chosen topic, you should use the Socratic Problem-Solving Approach, focusing on the sections specifically called out in the assessment guidelines.Topic 1: Limited Access to HealthcareShort Description:Consumers face barriers to healthcare access for assorted reasons. For example: due to geographic location, provider availability, transportation issues and mobility.Potential Intervention Approaches:– Healthcare information online– Telemedicine– In–home healthcare servicesKeywords for Articles:online health information seeking, health care access, health information systems, consumer health information, chronic disease, health information search, health seeking behavior, rural nursingReferences:Bhandari, N. (2014). Seeking health information online: does limited healthcare access matter? Journal of the American Medical Informatics Association: JAMIA (1067-5027), 21 (6), p. 1113., K., Hoti, K., Hughes, J. D., & Emmerton, L. (2014). Dr Google and the Consumer: A Qualitative Study Exploring the Navigational Needs and Online Health Information-Seeking Behaviors of Consumers with Chronic Health Conditions. Journal of Medical Internet Research, 16(12), e262.…Ware, P., Bartlett, S. J., Paré, G., Symeonidis, I., Tannenbaum, C., Bartlett, G., … Ahmed, S. (2017). Using eHealth Technologies: Interests, Preferences, and Concerns of Older Adults. Interactive Journal of Medical Research, 6(1), e3.…Pratt, D. (2015). Telehealth and telemedicine. Albany Law Journal of Science & Technology. (1059-4280), 25 (3), p. 495.…Topic 2: Healthcare DisparitiesShort Description:In 2010, the Federal Department of Human and Health Service (DHHS) launched the Healthy People 2020 goals to include a goal to eliminate health inequality/disparity. Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (Office of Disease Prevention and Health Promotion, 2017, p.1).Potential Intervention Approaches:– Federal goals– Community health improvement plans– Patient advocacy efforts– “Triple Aim” for populationsKeywords for Articles:health disparities, community health assessment, community health improvement plan, strategic planning, local health departments, health inequitiesReferences:Office of Disease Prevention and Health Promotion. (2017). Disparities. Retrieved from…Shah G.H., & Sheahan J.P. (2016). Local health departments’ activities to address health disparities and inequities: Are we moving in the right direction? International Journal of Environmental Research and Public Health. 2016; 13(1):44. for Healthcare Improvement. (2017). Triple Aim for Populations.…Topic 3: Medication ErrorsShort Description:A medication error is a preventable adverse effect of a patient taking the wrong medication or dosage, whether or not it is evident or harmful to the patient. Medication errors can be a source of serious patient harm, including death.Potential Intervention Approaches:– Medical staff education– Packaging improvements– Patient medication safety trainingKeywords for Articles:medication administration, medication errors, medication safetyReferences:Cohen, M. (2016). Medication errors (miscellaneous). Nursing. 46(2):72, February 2016. DOI: 10.1097/01.NURSE.0000476239.09094.06Institute for Healthcare Improvement. (2017). Improve Core Processes for Administering Medications.…Agency for Healthcare Research and Quality. (2012). Table 6: Categories of Medication Error Classification.…Schmidt, K., Taylor, A., & Pearson, A. (2017). Reduction of medication errors: A unique approach. Journal of Nursing Care Quality. 32(2), April/June 2017, 150–156.Topic 4: Healthcare System ErrorsShort Description:The health care system in the United States has been the subject of much debate as experts try to determine the best way to deliver high-quality care. In Crossing the Quality Chasm, the Institute of Medicine (2001) called for the redesign of health care delivery systems and their external environments to promote care that is safe, effective, patient-centered, timely, efficient, and equitable.Potential Intervention Approaches:– Systemwide transformation– Process redesign– Electronic health recordsKeywords for Articles:multi-stakeholder collaboration, healthcare system redesignReferences:Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US).Agency for Healthcare Research and Quality. (2017). Hospitals and Health Systems.…Roberts, B. (2017). Relationship-based care: The institute of medicine’s core competencies in action. Creative Nursing, 05/2016, 22(2).

Analyze a Current Health Care Problem or Issue
Learner’s Name
Capella University
NHS4000: Developing a Health Care Perspective
Instructor Name
August, 2020
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Analyze a Current Health Care Problem or Issue
Patient safety, as discussed in the previous assessment, is an important element of quality
health care. This assessment will expand upon patient safety issues that occur when patients are
exposed to inadvertent harm or injury while receiving medical care. Health care organizations
should maintain and develop a safety culture to prevent patient safety issues. Patient safety
culture is defined as a system that promotes safety by shared organizational values of what is
important and beliefs about how things work. It also encompasses how these values and beliefs
interact with the work unit, organizational structures, and systems to produce behavioral norms
(Ulrich & Kear, 2014). As such, care should be taken to improve the infrastructure of health care
organizations. Improving patient safety should be discussed and addressed by every individual
associated with public health care.
Elements of the Problem/Issue
Research shows that while getting treated at health care organizations, patients might be
at risk of experiencing the harm or injuries associated with medical care. The most likely causes
of patient safety issues are preventable adverse events, which are adverse events attributable to
error. These errors can be classified as diagnostic errors, contextual errors, and communication
errors (Ulrich & Kear, 2014).
Diagnostic errors take place when health care professionals provide a wrong or delayed
diagnosis or no diagnosis at all (James, 2013). An example of a wrong diagnosis is a health care
professional diagnosing a patient with gastric troubles when the patient is actually experiencing a
heart attack. An example of a delayed diagnosis is a patient not being notified of an abnormal
chest X-ray, thereby delaying diagnosis of a serious medical condition. An example of a missed
diagnosis is a patient not being diagnosed with heart failure despite warning symptoms.
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
Contextual errors occur when health care professionals fail to consider their patients’
personal or psychological limitations while planning appropriate care for them. An example is a
health care professional’s failure to recognize that basic follow-up discharge instructions may not
be understood by patients with cognitive disabilities (James, 2013). It is important for health care
professionals to be aware of their patients’ mental and physical abilities before they formulate a
plan of care.
Communication errors occur when there is miscommunication or lack of communication
between health care professionals and patients (James, 2013). They can cause severe harm to
patients. An example of this is a nurse failing to tell a surgeon that a patient experienced
abdominal pain and had a drop in red blood cell count after an operation, resulting in the death of
the patient due to severe internal bleeding. Limited health care knowledge; language barriers;
and auditory, visual, and speech disabilities could also lead to communication errors and cause
safety issues.
As a medical transcriptionist, it is important for me to be aware of potential transcription
errors and privacy standards, which affect patient safety. Errors like these pose dangerous risks;
therefore, it is necessary to have an overall quality evaluation of the transcribed documents.
Also, I must ensure that serious difficulties in transcription resulting from poor-quality voice
files are reported immediately to the manager, who will then convey this to the health care
professionals involved in the process. This will help ensure that patient safety is not
Context for Patient Safety Issues
With the advancement of medical technology, health care processes have become
extremely complex. Health care professionals are required to stay up to date with a lot of new
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
knowledge and innovations obtained from research. This often overburdens them as there is a
need to apply the learning from research in their practice. Also, at the individual level, there is a
dearth of well-balanced continuing education programs, which has resulted in a lack of attention
to patient safety among health care professionals. At the system level, organizations fail to
deliver optimum health care as a result of being understaffed, an inability to provide appropriate
technology, and ineffective execution of patient care transfer (James, 2013). Overcrowding and
understaffing delays initiation of treatment and puts critically ill patients at significant risk. All
of these factors contribute to a rise in patient safety issues.
Populations Affected by Patient Safety Issues
Patients with a psychiatric history are also a vulnerable group of people who face patient
safety issues because their psychiatric records are often combined with their current symptoms.
Patients with a documented history of psychiatric illness may avoid seeking health care services as
they feel that their care will be based on their past record of illnesses and not their present needs.
Therefore, psychotherapists should implement measures such that their psychiatric data is concealed
from their medical records before it is shared with the third party, which helps protect patients’
confidentiality (Shenoy & Appel, 2017).
Considering Options
Patient safety in hospitals can be achieved by creating a culture of safety that involves
effective communication, correct managerial leadership styles, and the use of Electronic Health
Records (EHRs). Effective communication while passing patient-specific information from one
health care professional to another is essential in ensuring continuous and safe patient care.
Training the team could likely improve consistent successful communication and help prevent
errors. Standardizing critical content that needs to be communicated by the initial health care
professional ensures safe transfer of care (Farmer, 2016).
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
It is essential for leadership teams to adopt organizational strategies that would improve
patient safety and transform their organizations into reliable systems for enhanced patient
satisfaction. They should set strategic safety goals, which could include adhering to standards of
health, assessing quality, using patient satisfaction reviews, and analyzing adverse event reports
to determine improvement in safety issues (Parand et al., 2014).
An EHR is another potential solution to prevent patient safety issues. It is a digital record
of a patient’s medical information that includes history, physical examination, investigations, and
treatment (Ozair et al., 2015). It helps manage multiple processes in the complex health care
system and prevents errors. EHRs utilize less storage space compared to paper documentation
and allow an infinite number of records to be stored. In addition to being cost-effective and
preventing a loss of records, EHRs help conduct research activities and provide quick data
transfer (Ozair et al., 2015).
In health care, because transmission of information takes place among different people
and electronic devices, there is a high likelihood of errors occurring. For example, transcription
errors (which occur due to poor audio quality or the lack of a quality evaluation process) can be
prevented by using recording equipment with good sound quality and by maintaining
proofreading and quality checks. However, integrating transcription processes with the HER
system helps prevent errors, helps access the required information faster, and allows health care
professionals to take accurate decisions about patients’ care.
An EHR is an important mechanism for improving patient safety. Its advancement has
made it a viable option to prevent medical errors. However, the use of EHRs has certain ethical
implications such as security violation, data inaccuracies, lack of privacy and confidentiality, and
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
challenges during system implementation. Security violation takes place when patients’
confidential health information is accessible to others without their permission. To avoid security
violation, data should not only be password protected but also encrypted to restrict access to
unauthorized individuals. Firewalls and antivirus software should be used to protect data (Ozair
et al., 2015).
Though EHRs improve patient safety by reducing medical errors, data inaccuracies are
increasing. Loss of data during data transfer leads to inaccuracies that affect decision-making
related to patient care. A problem of concern related to data inaccuracy is medical identity theft,
which leads to incorrect information being filed into a person’s medical record, which in turn
leads to insurance fraud and wrong billing (Ozair et al., 2015).
In health care, information that is shared during physician–patient interactions should be
kept confidential and should be made inaccessible to unauthorized individuals. Enabling rolebased access controls based on user credentials will restrict access to the EHR system to
authorized users. The user should also be made aware that he or she is responsible for any
information that he or she misuses (Ozair et al., 2015).
As EHR is a complex software, there is a high likelihood that software failure may result
in inaccurate recordings of patients’ data. Therefore, EHR system implementation may have
ethical implications due to the violation of data integrity (Ozair et al., 2015). EHRs can safeguard
patient confidentiality by using various methods that prevent security breaches. In addition to
this, creating reminders that ask for a confirmation before accessing confidential information can
help protect data. A nesting system could be developed, which would allow, for example, a
health care professional from a specific specialty clinic to access patient records by signing into
the specialty domain (Shenoy & Appel, 2017). These methods will enable the safe and efficient
use of EHRs and ensure patient safety.
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
Patient safety involves preventing the risk of harm or injuries to patients by establishing a
safety culture and providing high-quality medical care. Health care organizations must
understand patient safety issues and find solutions for these issues by designing systems that
prevent errors from occurring. Potential solutions include effective communication, changes in
leadership style, and the use of EHRs. The ethical implications of these solutions should be
considered before implementing them in a health care setting. It is also important that health care
professionals undergo continuous education and effective training, provide appropriate medical
care, prevent errors, and follow safety practices to improve clinical outcomes.
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
Farmer, B. M. (2016). Patient safety in the emergency department. Emergency Medicine, 48(9),
Flood, B. (2017). Safety of people with intellectual disabilities in hospital. What can the hospital
pharmacist do to improve quality of care? Pharmacy, 5(3).
James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital
care. Journal of Patient Safety, 9(3), 122–128.
Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health
records: A general overview. Perspectives in Clinical Research, 6(2), 73–76.
Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality
and patient safety: A systematic review. BMJ Open, 4(9).
Shenoy, A., & Appel, J. M. (2017, April). Safeguarding confidentiality in electronic health
records. Cambridge Quarterly of Healthcare Ethics, 26(2), 337–341.
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent
health care delivery. Nephrology Nursing Journal, 41(5), 447–456, 505. https://searchproquest-
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.
Copyright ©2020 Capella University. Copy and distribution of this document are prohibited.

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