Quality Improvement Proposal: Addressing Medication Errors Arising from Poor Communication in Surgical Wards
Quality Improvement Proposal: Addressing Medication Errors Arising from Poor Communication in Surgical Wards
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Quality Improvement Proposal: Addressing Medication Errors Arising from Poor Communication in Surgical Wards
- Patient safety risk concerns
- Purpose
The purpose of this quality improvement proposal is to recommend ways of reducing medication errors arising from poor communication in surgical wards. In such a setting, there is a need for effective communication among the hospital staff and other stakeholders to ensure better patient outcomes. Ineffective communication among healthcare professionals is the leading cause of preventable mistakes that compromise patient safety and prolonged hospital stays. Through the implementation of structured communication tools such as Introduction, Situation, Background, Assessment, Recommendation (ISBAR), this initiative seeks to improve the accuracy of communication of patient information, especially during clinical handovers.
- Background
Communication errors have historically accounted for a majority of medication errors and are the leading causes of adverse medical events. Proper coordination among the healthcare team is critical in ensuring effective patient care, particularly in surgical wards. The Australian Institute of Health and Welfare (AIHW) recognizes that patient safety concerns, especially communication lapses during clinical handovers, are the leading causes of preventable adverse events (AIHW, 2022). It is critical to concisely communicate medical information such as test results or abnormal vital signs. Lack of this communication can result in inappropriate or delayed treatment, which directly affects patient outcomes (Munroe et al., 2021). Structured communication tools, such as ISBAR, have been introduced in Australia to address these issues by standardizing clinical information conveyance, preventing misunderstanding and ensuring clarity during clinical handovers (ACSQHC, 2021). By implementing ISBAR in surgical wards, it is possible to reduce the high-risk clinical handovers where communication errors are often experienced.
- Objectives
This initiative aims at implementing ISBAR for clinical handovers and conduct interdisciplinary training on ISBAR among healthcare workers. This proposal recommends ISBAR as a mandatory communication tool for verbal and written clinical handovers within three months to ensure vibrant, succinct, and reliable communication among healthcare professionals. This strategy aligns with the best practices in structured communication and improved patient outcomes (AACSQHC, 2021). Secondly, the initiative aims to conduct a comprehensive interprofessional training on ISBAR protocol among nursing professionals, physicians, and ancillary personnel within six months. The aim of this training is to ensure all healthcare professionals are familiar with the protocol and that they adhere to the ISBAR communication standards during patient transfers and shift changes.
- Evaluation
The evaluation of this initiative will be conducted through both qualitative and quantitative measures using medication error tracking and staff feedback surveys. Quantitatively, medication error rates will be tracked before and after implementing ISBAR to assess the impact of the intervention. A reduction in the number of errors after the implementation of the intervention will indicate the success rate of the initiative (Singh et al., 2022). Staff feedback surveys will be used to collect qualitative data from healthcare staff to gauge their perceptions of ISBAR effectively in improving communication and reducing confusion during clinical handovers. Surveys will be conducted following the implementation of the communication protocol. Positive feedback and increased confidence in shift changes and patient transfers will indicate the success of the initiative.
- Stakeholder engagement
- Major stakeholders
The main stakeholders in this initiative will include the nursing staff, medical practitioners, pharmacists, patients and their families, the nurse unit managers (NUMs), and the hospital administration. The proposal recognizes nurses as critical professionals responsible for clinical handovers and medical administration. Medication practitioners also play an important part in medication prescription and depend on accurate information provided by nurses. In the healthcare system, pharmacists ensure accurate medication dosages and will rely on correct patient information for effective collaboration with other healthcare staff. This proposal also identifies patients and their family members as they are directly affected by the quality oof communication about medication administration. The NUMs oversee the operations of the ward and are pivotal inn implementing handovers. Finally, the hospital administration offers the needed resources and approve policy changes and staff training programs.
- Engagement and communication with stakeholders
It is critical to have an effective communication with stakeholder for the success of the initiative. In this regard, it is important to clearly explain to the stakeholders about the purpose of the initiative, which is to address medication errors using structured communication and its impacts on patient safety and hospital efficiency. Regular meetings with healthcare staff, including doctors, nursing staff, and pharmacists will also ensure that the stakeholders appreciate their participation in the initiative. To engage with the stakeholders, there will be formal communication, training sessions, and feedback loops. Having regular updates through emails, memos, and staff meetings will be critical in ensuring consistent messaging across the ward. The initiative also intends to employ interactive workshops to engage staff in learning about ISBAR and encourage active participation for the understanding of the tool. Lastly, feedback loops, including feedback channels and open forums will enable the stakeholders voice their con erns, report challenges and offer suggestions in real-time thus encouraging an inclusive environment where each stakeholder’s contributions are valued. The use of therapeutic communication principles, including listening, respectful, and clear language will also ensure that every stakeholder feels motivated and included in participating in the initiative (ACSQHC, 2018). This approach promotes mutual understanding and supports the role of cohesive team to enhance patient outcomes.
- Leadership style
The specific leadership style for the initiative will be transformational leadership, which is characterized by the ability of motivating and inspiring teams towards a shared vision, encouraging a collaborative culture, and continuous improvement. Transformational leaders have the ability to change the behaviours of staff by encouraging them in exceeding expectations (Lai et al., 2020). There are two main attributes of transformational leadership that will ensure the success of the initiative. These include inspirational motivation and individualized consideration. First, transformational leaders articulate a compelling vision and motivate staff in committing to the change initiative (Carney, 2016). By stressing on the importance of addressing medication errors and improving patient safety, this initiative will inspire stakeholders in embracing ISBAR as a mutual respomsbility. Secondly, individualized consideration will ensure that the needs and concerns of each member of the team are recognized. Through the provision of bespoke support such as additional training for members who may face challenges with the new protocol, the initiative will ensure that the team feels empowered and able to contribute to the success of the initiative (Duarte et al., 2021). According to Lai et al (2020), other transformational attributes include idealized influence and intellectual stimulation that can change the staff behaviours and encourage them to achieve the change goals.
- Barriers to change
The initiative will not be devoid of implementation barriers such as resistance to change. organizational and individual barriers are the widely recognized challenges to effective change management (Errida & Lotfi, 2021). For this reason, change management takes the approach of identifying the causes and sources of resistance and offer ways and tools to overcome them.
- Organizational barriers
Resistance to change is a potential organizational barrier that arises due to communication habits and existing workflows. It is possible that many staff members may display resistance in adopting ISBAR if they are used to unstructured or informal handovers. This form of resistance may arise from staff shortages, time constraints, or a reluctance to engage in additional training (Clegg, 2019). It is necessary to train staff on the new protocol to counter such form of resistance. Overcoming this form of barrier demands the support of hospital administration in allocating resources and time for gradual adjustment off workflows and training.
- Individual barriers
Individual barriers may include staff reluctance to embrace ISBAR protocol due to the lack of confidence in using a structured communication model. Doctors or nurses unfamiliar with the protocol may feel unsure of their ability to apply it effectively, particularly during high-stress events such as emergencies or burnouts which are common in the healthcare sector (Levett-Jones et al., 2010). In addressing this barrier, mentorship and additional practice session will be offered, ensuring that the healthcare staff becomes proficient and comfort in using the new protocol. Similar to organizational barriers, individual barriers will require the hospital administration in supporting the staff in training programs that will help them learn the new communication model.
References
Australian Commission on Safety and Quality in Health Care (ACSQHC). (2021). National Safety and Quality Health Service (NSQHS) Standards (2nd ed.). https://www.safetyandquality.gov.au/standards/nsqhs-standards
Australian Institute of Health and Welfare (AIHW). (2022). Health care safety and quality. https://www.aihw.gov.au/reports/australias-health/health-care-safety-and-quality
Carney, M. (2016). Understanding organizational culture: The key to successful middle manager strategic involvement in healthcare delivery? Journal of Nursing Management, 24(2), 91-100.
Clegg, S. (2019). Managing resistance to change: Key challenges in healthcare. Nursing Times, 115(10), 22-25.
Duarte, D. T., Goodson, J., & Klich, C. (2021). Leadership styles and their impact on healthcare outcomes: A systematic review. Leadership in Health Services, 34(3), 320-332.
Errida A, Lotfi B.(2021). The determinants of organizational change management success: Literature review and case study. International Journal of Engineering Business Management,13. doi:10.1177/18479790211016273
Lai, F., Tang, H., Lu, S., Lee, Y., & Lin, C. (2020). Transformational leadership and job performance: the mediating role of work engagement. Sage Open, 10(1), 1-30.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y., Noble, D., Norton, C., & Roche, J. (2010). The five rights of clinical reasoning: An educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. Nurse Education Today, 30(6), 515-520.
Munroe, B., Curtis, K., Considine, J., & Buckley, T. (2021). Clinical handover and patient safety: Identifying risks and opportunities for improvement. Journal of Clinical Nursing, 30(1-2), 7-16.
