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Policy Action Plan

Health Economics of Nursing & Health Policy

Brooke D. Smith

Delaware Technical Community College

NUR420-201 Nursing Policy

Bonita Blackman

February 19, 2023

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Although advocacy was not always an explicit expectation of the professional nurse,

Nightingale's early writings revealed her devotion to health, healing, and working in the best

interests of patients. The emergence of consumerism in the 1970s emphasized the nurse's duty

as a patient advocate. Currently, the fundamental concept of nursing in the twenty-first

century highlights the nurse's role as advocate. Nurses have a long history of advocating for

health, equality, and justice on behalf of and with patients, families, and communities (Mason,

Dickson, McLemore, & Perez, 2021).

Seventy percent of people in the United States take at least one drug per day, and more

than half take two. Every day in the United States, at least one person dies as a consequence

of a drug error, and roughly 1.3 million individuals are wounded as a result of medication

errors. We know that many errors get undetected unless there is an accident or death.

Underreporting has been attributed in part to the failure of a consistent definition of an error

(ANA, 2021). Is it necessary to disclose a "near miss" or an omission? The National

Coordinating Council for Medication Error Reporting and Prevention defines a medication

error as: "… any preventable incident that may cause or contribute to inappropriate drug

usage or patient harm when the medication is in the hands of the healthcare provider, patient,

or consumer” (ANA, 2021). Another element leading to underreporting is the fear of

punishment that still exists in the minds of certain practitioners/healthcare professionals.

Medication errors can be caused by human factors like distraction or a lack of knowledge or

information, but they are more typically caused by a defective system with insufficient backup

to identify mistakes (ANA, 2021).

Among the most frequent medical mistakes are those involving medications. More than

7,000 people die in the United States each year as a result of medication errors, which also
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prolong hospital stays and raise patient expenses. An average error costs between $2,000 to

$8,750 (Anderson & Townsend, 2015).

The medical community has been shaken by the RaDonda Vaught case. A former

Vanderbilt University Medical Center nurse was found guilty of criminally negligent homicide

and negligent maltreatment of an incapacitated adult by a Tennessee jury on March 25, 2022.

The prosecution and conviction were condemned by nurses, medical professionals, and

healthcare organizations as setting a risky precedent (Theriault & Kavanaugh, 2022). I can

definitely relate to Vaught as a nurse, especially as we battle a severe staffing crisis. If you

struggle through a challenging profession that is made much more challenging by working

longer than typical hours, the criminal charges she was facing probably mirror your darkest

nightmares. My coworkers and I have grown accustomed to handling larger patient loads while

juggling various high-stress activities while being tugged in numerous ways (Theriault &

Kavanaugh, 2022).

The Proposal

A nurse has begun advocating for "RaDonda's Law," legislation that would remove the

prosecution of medical errors. On May 24, Ms. Vinsant disseminated information to encourage

people to support legislation that would shield medical staff members from criminal prosecution

for mistakes they make. In order to prevent healthcare personnel from facing criminal charges for

making a good faith medical error while performing their duties, Ms. Vinsant said she is seeking

"to get legislation approved in the state of Tennessee" (Carbajal, 2022).

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The Institute for Safe Medication Practices of Tennessee

In order to educate people about adverse drug events and how to prevent them, the

Institute for Safe Medication Practices (ISMP), a nonprofit organization, collaborates closely

with healthcare professionals, institutions, regulatory bodies, trade associations, and the

pharmaceutical industry. The Institute offers an unbiased evaluation of medication errors that

practitioners have voluntarily reported to the United States Pharmacopeia's (USP) national

Medication Errors Reporting Program (MERP). USP may use the reports' information to

influence drug standards. The U.S. Food and Drug Administration (FDA) and pharmaceutical

firms whose products are referenced in reports receive access to all information obtained through

the MERP (TN Department of Health, n.d.).

The Institute regularly engages with the FDA as a partner in the FDA's MEDWATCH

program to assist in reducing pharmaceutical errors. The MEDWATCH program is encouraged to

receive accurate reports of drug errors by the Institute. With advancements in drug distribution,

name, packaging, labeling, and delivery system design, ISMP is committed to ensuring the safe

use of drugs. To help with problem-solving, the organization has created a nationwide advisory

board of practitioners. The ISMP releases the ISMP Medical Safety Alert, which offers guidance

on "safe practice" and information on pharmaceutical mishaps (TN Department of Health, n.d.).

Tennessee Legislature for RaDonda’s Law

A new law must be discussed and passed by the House and Senate on three separate days

(considerations). General bills are sent to the committee for assessment after their second

reading. The majority of the work is done here to determine if the measure should be updated,

revised, or not reported out of the committee. Bills that the committees approve are routed
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through the system so that the whole House can vote on them for the third and final time. A new

law must be approved by a constitutional majority. This implies it needs at least 50 votes in the

House and 17 votes in the Senate to pass. Once a new law has been approved by the House and

Senate, it is forwarded to the Governor, who can sign it or allow it to become law without his

signature. The Governor may also reject a bill by vetoing it. A constitutional majority is required

for the legislature to override the Governor's veto (Tennessee General Assembly, n.d.).

Governor Bill Lee (Tennessee)

Rationale: Representative to sponsor a bill

In the Event

Joint Commission

Rationale: The Joint Commission investigates situations that resulted in unexpected death,

serious permanent harm, or severe temporary harm necessitating intervention to preserve life

(Rodziewicz, Houseman, Hipskind, 2022).

Independent Double Checks

An independent doublecheck (IDC) can ensure that medications are administered safely.

IDCs can stop up to 95% of errors before they reach the patient, according to ISMP. In an IDC

that is carried out properly, the second nurse confirms that the patient, drug, dosage, and route

are accurate and follow the doctor's instructions (Anderson & Townsend, 2015). Patients' faith in

the nursing staff grows when they see them taking precautions to ensure their safety as nurses

explain the IDC procedure to them. So why don't all nurses perform IDCs if it's a tried-and-true
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method of lowering medication errors? IDCs require much time, according to ISMP research. A

normal shift for a nurse already includes around 25% time for administering medications. A

second nurse might not always be available to perform an IDC due to staffing constraints and

rising workloads (Anderson & Townsend, 2015).

Strategy to Implement Change

To make IDC documentation a "hard stop" with specific high-alert medications, they

collaborated with the clinical documentation team. Also, to expedite the IDC procedure, they

created individual barcode identification cards for each nurse that can be instantly scanned

without requiring manual entry for the details of the second nurse (Anderson & Townsend,

2015).

Limiting Interruptions

By breaking up the clinician's focus and attention, interruptions contribute to medication

errors. According to one study, every break during a single administration episode raised the risk

of making a pharmaceutical error by almost 12%. When there were four or more interruptions,

the error rate increased by two. Interruptions and distractions are caused by heavy workloads,

acute patient care needs, inadequate personnel levels, and a chaotic work environment (Anderson

& Townsend, 2015).

Strategy to Implement Change

Nurses should not be interrupted inside the no-interruption zone, created by enclosing the

space around the medication trolley in red tape. To act as a visible cue to other people not to

interrupt nurses giving out medications, they dress in vests that are either yellow or red. To
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reduce distractions, hospitals can also put caution warnings on drug dispensers and carts. By

filtering calls and posting detachable caution warnings on medicine carts during medication

delivery, they reduced communication during the administration of medications (Anderson &

Townsend, 2015).

Reducing Confusion

Many medicine names sound or appear similar and comparable to those of other

medicines. Medication errors are frequently caused by confusion about medicine names. To

name a few: Diprivan/Diflucan, dobutamine/dopamine, epinephrine/ephedrine, heparin/Hespan,

Humulin/Humalog, hydromorphone/morphine, Lantus/Latuda, Levemir/Lovenox, lente/Lantus,

Pavulon/Peptavlon (Anderson & Townsend, 2015).

In the case of RaDonda Vaught, she mistakenly confused the drug name Versed with

vecuronium bromide (Theriault & Kavanaugh, 2022).

Strategy to Implement Change

Using tall-man lettering and separating the pairs in dispensing devices and on storage

shelves are two methods for lowering errors caused by medications that look-alike, sound-alike,

or are perplexing. Identical packaging between drugs, and even within dosage strengths, might

confuse consumers and result in medication errors (Anderson & Townsend, 2015). Look-alike

drugs should be kept separate from more harmful prescriptions by pharmacists and nurses.

Hospitals should limit the number of look-alike medications by arranging them by category

rather than alphabetically (Rodziewicz, et al., 2022).

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Solution Proposal

When we meet with decision makers, we must first analyze and convey the two major

forms of errors, as well as how these two types of errors might have a detrimental influence on

patient care. Second, describe the most critical Joint Commission Patient Safety Goals, such as

the difficulties in error accountability and the impediments to error reporting. Subsequently,

distinguish between active and latent errors, as well as between adverse, negative adverse,

sentinel, and never events. Lastly, explain the significance of collaboration and communication

among interprofessional team members in reducing unnecessary errors and improving patient

outcomes (Rodziewicz, et al., 2022).

Action Plan

In the next 90 days I plan to meet with my unit manager, Bobbi Simkins, supervisors,

Natalie Moore and Debbra Parsons, and Risk Manager, Michelle Haines, physicians, and

pharmacists to create fundamental steps in improving medication safety in the hospital setting.

Together, we would keep updated pharmaceutical references and have those references available

when the prescription is prescribed. Ascertain that the nurses understand the patient’s condition,

diagnosis, and indications for the drug under consideration, including alternative therapy.

Evaluate doses, mode of administration, patient weight, renal and hepatic function, and other

critical patient variables, such as pregnancy, that may affect pharmaceutical efficacy. Recognize

the potential interactions between a newly given medicine and other medications the patient is

already taking, including non-prescription medications and supplements, as well as therapies

under consideration. Understand the possible risk of high-alert pharmaceuticals, which have a

higher chance of causing serious patient harm if a medication-use error occurs (The American
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College of Obstetricians and Gynecologists, 2012). I would conduct mandatory staff meetings

and skills days with physicians and pharmacists, where nurses could express areas of concern

and apply the action plans mentioned above.

Conclusion

Patient advocacy characteristics include safeguarding (tracking medical errors and

protecting patients from the incompetence or misconduct of coworkers and other members of the

healthcare team), informing (providing information about the patient's diagnosis, treatment, and

prognosis, suggesting alternatives of healthcare, and providing information about discharge

program), and valuing (maintaining self-control, allowing patients to make decisions freely, and

maintaining individualization a priority) (Abbasinia, Ahmadi, & Kazemnejad, 2020).

The standardization of medicine labeling, storage, concentrations, and dosages has

considerably reduced high-alert medication-related errors. IDCs and barcode scanning have also

aided. Using different strategies can further reduce errors. Staff education and buy-in are critical

to ensuring adherence to error-reduction measures and the overall success of interventions

(Anderson & Townsend, 2015). Knowing the medications, we deliver and how to administer

them correctly are critical for avoiding errors. While considerable efforts have been achieved in

mistake prevention, we have yet to achieve our aim of making HAM errors "never" events. We

can achieve our goal and assure the safety of the hospital patients in our care by exercising

vigilance, knowledge, uniformity, and automatic safeguards (Anderson & Townsend, 2015).
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References

Abbasinia, M., Ahmadi, F., & Kazemnejad, A. (2020). Patient advocacy in nursing: A concept

analysis. Nursing ethics, 27(1), 141–151. https://doi.org/10.1177/0969733019832950

American Nurses Association. (2021). Use of medication assistants/aides/technicians.

https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.nursingworld.org

%2F~498e32%2Fcontentassets%2Fa2ff1bd2d5ca467699c3bc764f7d9198%2Fissue-brief-

medication-aides-4-2021.docx&wdOrigin=BROWSELINK

Anderson, P. & Townsend, T. (2015). Preventing high-alert medication errors in hospital patients.

https://www.myamericannurse.com/wp-content/uploads/2015/05/ant5-CE-421.pdf

Carbajal, E. (2022). Nurses lobby for ‘RaDonda’s law’.

https://www.beckershospitalreview.com/nursing/nurses-lobby-for-radonda-s-law.html

Mason, D., Dickson, E., McLemore, M., & Perez G. (2021). Policy & politics in nursing and health

care. (8th ed.). Elsevier.

Rodziewicz T.L., Houseman B., Hipskind J.E. (2022). Medical error reduction and prevention.

https://www.ncbi.nlm.nih.gov/books/NBK499956/

Tennessee Deparment of Health. (n.d.). Patient safety practices. https://www.tn.gov/health/health-

program-areas/tips/patient-safety-practices.html

Tennessee General Assembly. (n.d.). About the Tennessee legislature.

https://www.capitol.tn.gov/about/
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The American College of Obstetricians and Gynecologists. (2012). Improving medication safety.

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/08/

improving-medication-safety

Theriault, A. & Kavanaugh, C. (2022). Medication errors lead to a criminal conviction: what

nurses should know about the RaDonda Vaught verdict.

https://www.jdsupra.com/legalnews/medication-errors-lead-to-a-criminal-7048355/