Medication Errors in Mental Health Care

1. Introduction

A medication error is referred to the preventable event that is able to lead inappropriate administration of medication or cause harm to the patient while administering the medication by the health professional or the nurse which is under their control (Wolf et al. 2015). These events are seen to cause an adverse effect on the health of the patients as well as raise question regarding the professional efficiency of the health professionals and nurses. In relation to this, the extended literature review is structured to identify the causes and responsible factors that contribute to create medication error with a particular focus on the mental health inpatients. The identification of the topic was made while on the placement at the mental health inpatients unit where the patients were seen to be highly dependent on proper administration medication to ensure they remain mentally conserved and behave properly in the surroundings.

1.1 Why search this area

There are wide numbers of studies that states medication errors occur in the mental healthcare settings and out of the total number of errors few are considerably severe that may bring extensive negative consequence for the patients. It is evident as in the observation study conducted by Cottney and Innes (2015), it was seen that after 172 medication rounds made for observation 139 medication errors were detected in 4177 opportunities (3.3%). Further, out of the nature of medication error mentioned 15 of the errors which range to 11% were reported to bring severe consequences for the patient’s health in the mental hospital. In another study of Soerensen et al. (2016), it was mentioned that 189 errors are detected by the researchers on 1,082 opportunities that range to 17% and in 8% cases, this medication error was termed to be potentially harmful the mentally-ill patient in the mental health setting. It is also reported in a study that 10-42 errors per day occur among 1000 patients in the UK and 28-31% of them are severe with 1.4-2% medication error being life-threatening in the mental health settings in the UK (pharmacyresearchuk.org, 2018). These figures indicate that the extent of severity of the medication errors caused in mental health setting is able to create potential hindrance for the health of the mentally-ill individuals. It is evident as improper administration of medication, inappropriate dosage and timing of medication and other nature of medication error mentioned in these two studies were seen to show that proper medicine required by the mentally-ill patients to control their ill mental state was not provided. In the UK, total of 72 deaths of the patients was reported due to medication error out of which 1 patient was found to be receiving care in the mental health settings. The NHS in the UK reports that 237 millions of medication error is caused each year in the country due to which patients face severe health consequences that rarely amount to death in different healthcare service sector such as community care, general hospital, mental health services and others (improvement.nhs.uk, 2018; www.manchester.ac.uk, 2018). The figures indicate that the condition of medication error is at a deteriorating stage in the country where patients in the mental healthcare settings as well as in other field are facing problems with accessing proper quality care as a result of an error caused by the health professional and nurses while administering or prescribing medications. As mentioned by Slemon et al. (2017), improper administration of the medication to the mentally-ill makes them more impulsive, aggressive and anxious in nature. This result the nurses to face difficulty in controlling the health of the mentally-ill patients. Thus, research in the area is executed so that key causes of medication error are identified along with the challenges that are creating the errors so that better healthcare services can be provided in the mental inpatient settings.

1.2 Aim

The aim of the study is to identify the causes and factors related to medication errors in mental health inpatients units and the way they can be resolved or reduced to ensure proper and right quality care to the service users or patients.

1.3 Way to explore the aim

The aim of the study is to be explored by identifying, evaluating and analysis the results and findings mentioned in different previous literature and articles that have been written based on the topic being explored in the study. Later, based on the information the changes to be made in practice are to be mentioned along with the nature of change, leadership and management required to fulfil it is to be discussed. Lastly, reflection is to be provided to inform regarding the way the overall review of the literature and management led to the fulfilment of the aim.

2. Searching the Literature

2.1 Narrative of Search Strategy

The search strategy to be used in executing this study is analytical research strategy. In analytical research strategy, it is seen that the researcher studies and analyses the available data retrieved from the existing literature for developing proper information to resolve the raised problems in the study to finally meet the aim. This search strategy is seen to help the researcher to critically appraise the detailed information of the paper for developing new ideas to meet the aim of the study by resolving identified research problems (Milner et al. 2015). Therefore, it is beneficial to use the analytical search strategy as it would help the researcher to identify enriched information for properly meeting the aim of the study.

2.2 Research Question

In order to formulate the research question, the PICO technique is to be used in this study. PICO is referred to the process that is used for executing evidence-based practise so that the question is framed in such a way that it directly answers the clinical query raised in the study (Eriksen and Frandsen, 2018). The PICO tool stands for Patient/Problem, Intervention, Control and Outcome. The problem is referred to as the clinical issue that is identified in the study. The intervention means the area of interest the study require focusing to resolve the raised health issue. The control refers to other strategies able to prevent the problem and the outcome refers to the desired effect that the researcher perceives to get after resolving the problem (Siegfried et al. 2018). Thus, according to the PICO framework the research question of the study is as follows:

2.3 Evidence on literature searching

The literature to be searched would be done by using variety of relevant electronic databases such as Google scholar, PsycINFO (psychological literature), HMIC (health management literature), Cochrane Library (Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects (DARE), MEDLINE (medical literature), ISI Web of Knowledge Database (social sciences literature), CINAHL (Cumulative Index of Nursing and Allied Health Literature) and others. The databases are going to use certain keywords developed from the study which are to be interrelated through Boolean operators while searching to identify potential literature regarding the topic. The search is to be executed by taking relevant papers from 2008 to 2018 to ensure most current evidence are presented in the literature.

2.4 Inclusion and exclusion criteria

3. Literature Review

The papers mentioned in the literature review were thoroughly analysed and evaluated to identify common themes related to the topic. The use of the thematic analysis method in the study is beneficial as it helps to summarise key features from a large body of data ensuring the enriched description of the collected evidence (Braun et al. 2019). As mentioned by Shepherd et al. (2015), thematic analysis is easy and flexible to be used. Thus, it can be implemented by researchers with little knowledge regarding the way to conduct qualitative research and so the method is to be used in the study. Moreover, thematic analysis helps the researcher to generate unanticipated insight into the data making way for presenting valuable and enriched evidences in the study.

3.1 Nature and frequency of medication errors in mental inpatient units

Medication errors are referred to the preventable situation in which wrong or inappropriate medication is provided to the patients unintentionally without the control of the situation within the scope of the health professional. In the study of Alshehri et al. (2017), it is reported that out of the 20 studies being reviewed that are related mental healthcare it is seen that the frequency of medication error ranged from 10.6 to 17.5 per 1000 individuals accessing care per day. The frequency of adverse drug events due to medication error ranged from 10 to 42 per 1000 patients out of which 13-17.3% of the adverse events are able to be prevented as reported in the study. Out of the total number of adverse medication errors in the mental health setting, the study informed that 66-71% of them were clinically significant, 28-31% of them are serious and 1.4-2% of them are life-threatening. In this study, most of the medication errors are reported to occur in association with psychotropics drugs mainly. The figures of frequency and nature of medication errors in mental inpatients units indicate that it occurs commonly in mental health scenario and effective intervention are to be taken to prevent it. This is required to promote the health condition of mentally-ill patients in an appropriate manner. In another study executed by Sahithi et al. (2015), it is reported that over the period of detecting medication errors 215 errors are identified from 166 patients who were receiving care in the mental inpatient unit in a tertiary hospital. This indicates that the average incidence of medication error per patient was found to be 1.3 and the average number of patient who was involved in medication error was 2.1. The dose omission was found to be the most common nature of medication error at it occurred 42.12% times. The wrong technique of administering medication error was 11.57% and wrong administration was seen in 10.60% cases. These figures indicate that medication error occurs at a concerned rate and frequency in mental health settings and strategies are to be implemented to control its occurrence. It is required to ensure the right and quality care for positive mental health outcome of the patient.

3.2 Causes and Factors responsible for creating medication errors in mental health

In the studies being analysed, it is found that wide number of factors are responsible for causing medication errors in the mental health settings. In the study of Keers et al. (2018), it is informed that skilled based error such as slips and lapses was reported to be made by 13 of the total nurses interviewed that leads them to cause medication error in mental health settings. This is because during lapses the nurses lost concentration on what medication they are selecting from the lot to administer or give to the mentally-ill patients. It is evident as one of the nurses interviewed in the study explained how her lapse or loss of concentration lead her to administer co-codamol to patients instead of codeine while being busy which she later identified was not prescribed for the patient. The study of Keers et al. (2018) also mentioned that lack of proper knowledge regarding which medication is prescribed for particular patient in mental health setting lead nurses to cause medication errors. This is because without proper knowledge of the prescribed medication and the details of the reason for its administration the nurses become confused which medication is to be provided to particular patient leading them to execute medication errors. The study mentioned violation of rules at work by the nurses leads to cause medication error in mental health settings. It is evident from the instance mentioned in the study where it is informed that one of the nurses who was not routinely working in the ward caused medication error by misidentifying a service user while allocated in the ward to administer medication leading to medication error. This is because the nurse was not informed that there are two patients with same name but their date of birth are different that was to be used for identifying which patient is to be given which prescribed medication as per the doctor. In contrast to the previous study, the article by Jhanjee et al. (2012) informed that illegible handwriting of the health professionals is one of the causes of medication errors in mental health scenario. This is because illegible handwriting leads nurses to misread the names of the medication due to which they give wrong medication to the service users. The fact can be supported through the study of Keers et al. (2018) where it is also mentioned that medication errors in the mental inpatient units occur due to lack of proper written communication. It is evident as the prescription on which the drugs to be administered to the patients are written unclearly or had crossed parts that lead the nurses to face hindrance in identifying the actual name of the medication to the administered to each patient. Moreover, Jhanjee et al. (2012) report that lack of clear instructions to the patients in the medical settings to take proper medication leads to medication errors. This is because the patients lack the knowledge of proper amount of dose of medication to be taken leading them to take increased or less dose of the medication orienting to cause medication errors. On comparing the study of Keers et al. (2018) and Jhanjee et al. (2012) it is found that the present study like the previous one mentioned that lack of proper instruction to the nurses regarding the way they are to offer medication to mentally-ill patients leads to medication error. This is because the nurses are not knowledgeable about the right amount of prescribed medication to be offered to a particular patient.

The study of Jhanjee et al. (2012) also mentioned that medication error due to the use of prescribed drugs with the same instruction and indication amounted to cause 15% errors. The errors are experienced because the nurses with the same instruction and indication for each medicine made them confused regarding which particular medication to be given to which particular patient in the mental health settings. In contrast to the study, the paper by Maidment and Parmentier (2009) informed that the risk of medication errors arise in mental health settings due to lack of proper training and familiarity of the nurses with certain drugs that are used for the treatment of the service users. The lack of proper training and familiarity act as reason of error because without proper training the nurses are unable to know which medication is to be provided in which way so that the proper dose of the medicine as prescribed reaches the patient’s body to react to control their health issues. In comparison to the study Maidment and Parmentier (2009), the article by Ayani et al. (2016) informed that inadequate monitoring of the patients before giving them medication is one of the causes of medication error in mental inpatient units. This is because lack of proper monitoring leads the nurses to inappropriately conclude they are offering right medication and could not even check through follow-up process whether or not the medication offered to the patient was right or wrong leading them to face errors at work. However, the study of Keers et al. (2018), informed that medication error occurred in mental inpatient units because the nurses interrupted the medication administered to attend another patient or activity. This leads the nurse to lose concentration on the dose and nature of prescribed medication being offered to the patient making them execute unnecessary medication error. The study also informed that increased number of patients being present at the same time with less number of nurses in the units leads to medication errors. This is because nurses are unable to manage to provide proper medication as per prescription due to increased pressure to offer services to more than one patient at the same time. The quantitative study of Al-Kandari and Thomas (2009) regarding Kuwaiti nurses informed that extensive workload was potential reasons that lead to create medication error and safety issues. In another study by Maurer (2010), it is seen that out of 800 registered nurses in America who were chosen randomly for the study 60% admitted to have caused medication error in the last 12 months. These nurses mentioned that as a result of long shifts and uninterrupted working hours was a reason behind them to cause medication error. This is evident as the study of Symon et al. (2006) also informed that work load and mismatch of skills are potential causes that lead to cause medication error by the nurses.

3.3 Impact of medication errors in mental health

The impact of medication errors is found to adversely impact the mental health of the patients accessing care in the mental inpatient units. In the study of Haw et al. (2007), it is informed that medication error for the mentally-ill individuals has lead to deterioration of their psychological health. This is because proper medications that are prescribed to control the emotions and anxiety of the mentally-ill patients are not provided as a result of the error. Thus, the psychological balance demanded to be supported through the medication is disrupted making them show improper behaviour. Moreover, medication errors are found to cause deaths in intense cases where the error was severe (Procyshyn et al. 2010). This leads to depress the family members with the thought that it was possible to cure the person and avoid their death if proper medication was being provided in the inpatient unit. The impact of medication errors on nurses and health professionals in mental inpatient units is that providing wrong medication leads them to suffer guilt, shame and self-doubt while providing care (Tomes, 2006 Moore and Mattison, 2017). This is because the patients and the family members of the patients blame them in the public for irresponsible care. Moreover, creating error in administering medication when revealed lead the nurses and health professional think that they are incompetent in offering to care to the service users making them lose self-confidence and develop self-doubt. As asserted by Maidment et al. (2006), doubtful practice in medication leads to provide improper care services to the service users. This is because the doubt leads health professionals to remain in confusion about the nature of the care they are to offer to achieve success and get positive health outcome for the service user. As argued by Waterman et al. (2007), medication error may lead raising lawsuits against the health professionals in mental health settings. This is because the medication error causes damage to the health of the patients which makes the family members of the patient ask for compensation through lawsuits from the health professional. The impact of medication error in the hospitals where the mental inpatient units are present is that their reputation of the organisation would be hindered (Rothschild et al. 2007). This is going to lead many patients to avoid accessing care from the health institutions as they would fear that quality healthcare services would be provided to them required for their positive health outcome. Moreover, the medication error in the mental inpatient's units would lead the hospitals to face lawsuits for which they would face financial obligation to provide settlement cost and compensation to the patients who are negatively affected by their activities of error (Heinz et al. 2016). This would lead to negatively promote the name and image of the hospital leading mentally-ill patients to face confusion whether or not they are receiving error-free services while accessing care from the mentioned organisations with reports of causing medication errors.

3.4 Strategies implemented to resolve medication errors in mental health

The implementation of effective strategies is required to resolve medication error in mental inpatient units to ensure positive health outcome of the patients. In the study of Vivekanantham et al. (2017), it is informed that the nurses and health professionals in the mental inpatient units are required to have knowledge of each medication required by particular patient and properly follow medication reconciliation procedures when a patient is transferred from one ward to another within the same institution in the mental inpatient unit. In order to execute this process, the nurses and health professionals are required to review as well as verify each of the prescribed medication required by each of the patients to ensure that after the change the patients receive correct medicine along with proper dose and correct way of administration. This is to be meet by mentioning correct medication, way of administration, correct dose and correct time in the transfer documents of each patient by the nurses. In order to ensure, the list is properly done the nurses require rechecking the contents with the medication administration record of the ward. In contrast, the study by Kothari et al. (2016) informed that nurses to ensure medication error do not occur in the mental inpatient's units they are to make sure the medication transcription that is related to institutional policies are effectively followed. The nurses require knowing that it is not sufficient that they transcribe the medication as prescribed to the patients to avoid error. They are required to ensure for avoiding medication errors is that the correct medication in right dose and in right way of administration along with correct time of administration is fulfilled. The study also informed that the nurses to avoid medication error in mental health settings during shit change are required to ensure that the new incoming nurse is properly communicated about each patient’s order regarding medication. They are also to ensure that the new incoming nurse in the shift has the proper knowledge to correctly transcribe the medication as prescribed for each patient by the physician through understanding and analysing the treatment administration record and medication administration record. In another study by Wheeler et al. (2018), it is informed that to avoid medication error the nurses are required to read back a medication order to the physician who has prescribed it for ensuring that the mentioned medication is correctly transcribed. This activity is required to be executed by the nurse where they are unable to properly understand the handwritten communication of the physician or other nurses. In order to avoid medication error due to similar names of the patients, name alters are require to be installed in the medication administration for such patients. This is required to help the nurse to become concerned in differentiating being similarly named patients while providing medication, in turn, avoiding medication error (Mekonnen et al. 2016). In the study of Paton et al. (2016), it is mentioned that all the things regarding medication are to be properly documented for follow-up process to ensure that no medication errors have occurred. This involves proper documentation of label on the medication, other legible documentation or proper record of given medication. It is required for preventing the medication error in the sense that no other nurse re-administer the medication to the patient when it is already been given. This is because it would lead to create an increased dose of administration of the medication which is also a nature of medication error that is not effective for the patient’s health in the mental healthcare settings. The study of Herbert et al. (2018) informs that proper storage of medication is to be maintained by the nurses in the mental health settings to ensure efficacy. This means that the nurses require keeping medications that are to be refrigerated before use in the freezer and those that are needed to be in the room temperature in the room. Moreover, to avoid medication errors the nurses in the mental inpatient units are to make sure the medicines that have expired are removed and not used for any purpose to treat the patients. As mentioned by Townsend and Morgan (2017), nurses to avoid medication error in hospital are required to develop detailed knowledge about the medication administration rules, legislation and guidelines of the institution. In order to fulfil the condition, the management requires educating the nurses in this respect by arranging workshops and events. This is required as the medication policies are seen to have varied vital information regarding medication practice, ordering, documenting, transcribing and administering to patients in the institution.

The nurses and health professionals to avoid medication errors require having a drug guide being available at each time. This is because the drug guide includes generic as well as trade names of all medicines along with the therapeutic class, dosing, nursing considerations, cautionary measures and others required to be considered in the right determination of medication to be administered to patients due to any nature of communication issue. It means that if nurses get confused regarding the (generic) name of medication mentioned in the prescription they can consult the drug guide to identify the trade name for effectively identifying the key medication to be administered to the patient. However, another study informed that nurses and health professionals are to be provided mental relive at work so that they do not feel stressed. This is because stressful work environment with the burden of tasks is seen to lead nurses being unable to properly manage proper medication administration to the patients in the mental inpatient units as well as in other units in the hospital (Keers et al. 2018). As argued by Moss et al. (2016), nurses are required to work collaboratively and with coordination with one another to avoid medication error. This is because collaborative work environment leads nurses to have effective communication with any nurses to discuss the right way of administering and managing medication in case of patients of mental inpatient units to reduce medication errors.

4. Changing practice

The literature informs that increased medication errors that are sometimes severe and adverse are happening in the mental inpatient's units without intention from the nurses and health professionals. This has lead to create hindered healthcare services to the patients as well as impact on creating doubt on the professional efficiency and integrity of the health professionals (Maidment and Parmentier, 2009; Jhanjee et al. 2012).The change I propose to resolve medication error in the mental inpatient units is introducing an automated medicine dispensing cabinet. The Automated Dispensing Cabinet (ADC) for medicine is a locking cabinet which controls the access to medicines for inpatient units. The nurses are able to gain access for the cabinet by use of a password or by scan of their fingerprint. The touch screen is then used by nurse to select a patient and the required medicine needed for the patient to be administered. After the selection of patient and medicine name on the screen, the cabinet is opened to allow the nurse get access to the particular medicine only and it guides the nurses to get access the location along with mentions the amount of dose of medicine to be administered to the patients through the touch screen. The study of Cottney (2014) indicates that this nature of ADC is already installed in many hospitals in the US which have seen to potentially reduce medicine errors and time taken for administering medication to the patients. Moreover, I propose that the nurses are to maintain medication register for each patient that is to be handed over next nurse in the shift to let them understand what medicine is already provided to which patient and what medicine are left to be administered. The nurses are to be trained and educated regarding nine rights of medication administration so that medication error while administering medicine can be avoided in the units. In order to ensure the change that is reduction of medication errors in mental inpatient units is achieved, follow up process and proper patient monitoring is to be done after the implementation of automatic medication cabinet in the unit. This is because patient monitoring and follow up process helps to identify whether or not the patients are satisfied with the nature of care after it is provided. Moreover, patient monitoring helps to identify whether or not the health of the patients have progressed after the treatment and medication offered to them (Mira et al. 2015). The reduction of medication error with the help of ADC is going to ensure offering right medication to the patients required as per their health condition, in turn, would offer positive health outcome for them due to right implementation of treatment.

5. Leadership, Management and Change

In order to implement the change, various management styles, model and theories are to be used to ensure all the barriers related to the change are identified and resolved with the help of implementing the concept of change models and theories. The PDSA model is referred the model that is used to test the change which has been implemented. The PDSA model informs about four steps to follow that include Plan, Do, Study and Act. In order to make the change, while going through the mentioned steps it is seen to help in providing guidance regarding the way to think for successful implementation of the change by breaking each task into several steps. Moreover, this model helps to identify way to improve the change and test it again to ensure successful implementation of the change (Vordenberg et al. 2018). The plan indicates at the initial stage to understand the process and then it refers to propose a changed action required for improvement followed by taking decision regarding the way changed action has to be executed and tested to determine the way the changed action is going to have impact (Langley et al. 2009). The implementation of the changed action is executed in the “Do” phase and the “Study” phase includes the results and effect of the new changed action along with comparing it with the expected outcome. The “Act” phase which is the final stage is going to analyse the discrepancies experienced in the outcomes (Cousins, 1998).

The benefit of using the PDSA model is that it helps in increasing the confidence of the individuals in making the change (Montero and Moffat, 2017). This is because the model helps to test extent of success of the change before its actual implementation assisting to redefine and adapt ideas regarding change. The other advantage of using PDSA model is that it helps the change to be tested creating time for the individual to make alterations in the determined change according to local condition where the change is to be implemented. Further, the benefit related to PDSA model is that it helps to identify the side-effects of the change and minimise the resistance of making the change by highlight the barriers to be resolved to implement the change successfully (Morelli, 2016). The Kotter’s Model indicates that to create change successfully eight steps are to be followed that are establishing a sense of urgency, forming a powerful coalition, creating a vision, communicating the vision, planning and creation of short-term goals, consolidating improvement and production of more change and institutionalising new change approaches. The Kotter’s model to establish a sense of urgency for the change informs to examine the situation and identify as well as create a discussion of the potential crisis related to the situation which would act as a catalyst for creating the change (Small et al. 2016). This is evident as examination of the situation leads to highlight the extent of crises the situation is creating making others become concerned to think of creating the change to resolve the crisis. In order to accomplish coalition, the model informs that a group of people is to be assembled who are able to lead the change. The creation of vision indicates that goal is to be viewed and strategies are to be made in mind that would help to direct in making the change. Communicating the vision stages indicates the use of each channel and mode of communication to inform the strategies and goal of change to others (Chappell et al. 2016). This is required to let all individuals within an organisation know what nature of change they are to accept and execute to resolve the present crisis situation. The empowering others stage informs that the core group developed for the change are to made sure all others in the surroundings are offered education, training and other information to understand the way each has to act to make the change successful. The planning and creation of short-term goals help to testify the success of each aspect of the change. The consolidating improvement and production of more change include implementing better approaches along with reinvigoration of the process to successfully reach the change. The institutionalisation of new approaches stage of the model informs that connections between new changes and success are to be created through the development of proper leadership for the successful establishment of the change (Teixeira et al. 2017).

The Total Quality Management model informs about eight key principles are to be followed to ensure proper quality of the services is achieved. The principles include executing focus on the needs and demands of the target individual, proper leadership, effective involvement of right people, processed approach, systematic approach to manage, continual improvement, effective decision-making approach and developing mutually beneficial relationships (Jarrett, 2016). The implementation of the TQM model in the aspect of change development is that following the principles of the model would help to identify ways in achieving the change in a qualitative manner. The Mckinsey 7-S model is another concept that can be used in making the proposed change. The Mckinsey 7-S model is usually used as a tool for analysing the organisation design of the institution by focusing on seven key internal elements to identify if they are properly aligned or not to help the organisation achieve its objectives (Somsriruen et al. 2018). This model is to be used for making a successful change in the sense that it would help to identify and analyse whether or not the key seven internal factors of any institution remains properly aligned due to the change. In case they do not remain aligned due to the change, the management is going to develop new approaches related to the change so that it can be made in such a way that the factors are realigned with the objectives of the institution.

Rationale for selecting the Change model

The study by Massoud (2001) informed that ideas regarding improvement in healthcare initiates from various sources such as a leader who has detected gap in the objectives of the organisation or in some cases where the team identifies a gap which is related to the organisational activities, negative reports of the public regarding quality indicators in care practices that serve as impetus to create projects related to quality improvement. Moreover, it is mentioned that approaches regarding quality improvement include taking decision regarding which resources to be used depending on the situation or circumstances. This is because some issues can be simple which can be easily resolved whereas some issues are intricate that requires the implementation of extensive core process as well as needs effective research. The view was seen to be supported in the study of Kotter and Schlesinger (2008) where it is mentioned that efforts regarding change failed because the managers were unable to tailor proper resources and approaches with the speed of accomplishing the strategy in the right time to resolve issues related to the situation. Thus, this indicates that as a result of proper source selection ability, maintaining situations and speed needed for resolving and making rapid changes in any situation the PSDA model for improvement is being selected. In addition, this model was seen to be selected because it is practically implemented in 35 healthcare systems by the Institute of Healthcare Improvement (IHS) present in the US as well as are recently adopted in different countries in the UK and Australian continent (Langley et al., 2009). This is required and effective as the study by Langley et al. (2009) informed that PSDA cycle is not implemented to replace the change model of the organisation but to increase the speed of their improvement. The fact was supported by the study of Smith (2011) where it was mentioned focus related to the improvement of quality and implementing change together act as a powerful combination. The Kotter’s eight step change model is being implemented with the selected change model. The Kotter’s model informs eight reasons regarding reading the failure of an organisation in turn mentioning which eight key aspects are to be considered for getting successful change in organisation. This means that by ensuring the key eight aspects are removed or contained or at the minimum actions are implemented to decrease their impact it would lead to successful flow of change. The study of Sidorko (2008) states that eights steps in the Kotter’s model is divided into three categories that include preparation (1-4 stages), action (5-7 stages) and grounding (8th step).

Change Model

Question 1: What are the improvements we are thinking of accomplishing?

On the basis of the feedback received from HIQA inspection along with the auditing of the present practices by using auditing tool that was implemented by HES 2009, the following problems or issues are being discovered:

1. Interruptions during medication administration, nurses by passing processes which supports smooth running of medication administration, non-compliance with protocols, heavy workload, fear of disciplinary action, fear of punishment, high level of anxiety, long day shifts, tiredness

2. No proper reporting of error incidences regarding medication

3. No medications are reviewed on regular basis

4. Medicines that required judgment of the nurses to be implemented are packed in blisters packs which could lead to adverse medication error

5. Medication administration record sheet not properly maintained

6. Medications are not properly stored

7. Controlling of medicine or drug registers as per HIQA standards are not met

8. 9 principles of safe drug administration were not properly implemented

9. No training is received by the nurses at work

The above-mentioned problems conclude that the present practice is error-prone in dispensing or administering medicine or medicinal drugs to the patients which may lead to cause severe negative consequences. The study of Langley et al. (2009) indicates that before the implementation of an improvement project it is necessary that the managers are to work and interact with the people who are included in the change to inform them about the systematic goals in which they are to work and assist them to identify each step through which the goals are to be accomplished. Thus, it indicates that the project manager is required to present the information regarding the change to the stakeholders such as employees, nurses, pharmacists, care manager and others in the organisation who are involved in any aspect of managing medication. This fact was supported by Proctor and Doukakis (2003) where they mentioned that to make successful change the people who are to be involved in the process are to be interacted at an early stage as well as consult with them in making the change. In relation to this process, three aims are agreed on which are: 1) implement Automated Dispensing Cabinet (ADC) for medicine in the mental inpatient unit 2) increase compliance of the staffs by 90% to the nine rights to be considered in providing and administering medication in the next 3 months 3) reduce medication errors within 3 months by 90%.

Question 2: How to know that the change is going to bring improvement?

In order to ensure that the change has brought improvement, feedback and data regarding patient’s health are to be collected before and after the change. Moreover, the rates of medicine error are to be determined before and after the change implemented to ensure whether or not improvement is changed through the planned change. This is because before and after data helps to create comparison to understand the impact of the change as increase in medication error after implementation of the change would indicate unsuccessful change whereas lowering of medication error after the change indicates successful change.

Question 3: What changes are to be made so that it will result in decreasing the medication error?

The inspection report and findings from the audit along with the literature review informs that implementation of automatic dispensing cabinet for medicine is to be installed along with the workload of the nurses are to be reduced and they are to be offered training to achieve improvement. This indicates that the new practices are going to involve: 1) the storage of patient's data and the specific medication being prescribed for the person along with the dose to be administered in the software that operates the automated dispensing cabinet for medicine 2) medication incident report along with medication register by the nurses for each patient 3) training and reduction of work pressure on the nurses.

1. Plan Stage:

The study of Langley et al. (2009) indicates that in the Plan stage the objectives of the analysis are determined and predictions are made regarding what and how is going to happen and why the change is required. In relation to this, according to Gupta et al. (2008), planning stage requires the collection of data to quantify the extent of worst the problem is so that changes can be determined to improve them later. In addition to the information received, the internal stakeholders that are nurses, health practitioners, pharmacist and others in the mental inpatient unit developed an action plan for the change to be implemented. The activity is consistent with the facts mentioned by O’Neal and Manley (2007) where they informed action planning is the key way to achieve change in practice. The authors further informed that the involvement of others in framing the action plan allows the intended change to be effectively achieved. This stage is argued to be similar with the Kotter's fifth stage which recommends the need of empowering people in the organisation to make them act with a clarified vision to meet the mission of the organisation (Smith, 2011).

2. Do Stage

The stage includes the process of carrying out of the framed plan, documentation of the problems along with making unexpected observations and analysis of the gathered data (Langley et al. 2009). In order to ensure successful implementation of the stage, the sixth step of Kotter’s model is included which informs that planning for short-term purposes is to be done which would enable the change and assist in recognising the achievement made along with identifying those whose work allowed the change (Smith, 2011). Therefore, the new system of change determined was implemented on 1st November and tested for next three months. The Fore Field Analysis (FFA) technique is referred to the process in which diagrammatic display of main forces acting in a situation that is responsible for a planned change is done in order to use to understand which forces lies in which situation and how they are to be used to resolve problem or plan the change in an effective manner (Lewin, 1952). The first step of FFA is to detect the main driving forces and promote them to be shifted in a desired direction. The second step includes estimation of the strength of each force and represents them through the length of the arrow. The third step is developing specific objectives for change that are going to impact on increasing driving forces as well as decrease restraining forces along with changing the restraining forces into driving forces (Pearce and Robinson, 1989). Thus, FFA is implemented to identify the barriers as well as positive factors related to the change. The barriers faced in this change are: 1) lack of proper storage facility of medicines 2) lack of IT staffs to ensure management of ADC 2) improper infrastructure 3) staff fear of punished if the error is reported. In order to resolve the barriers, better leadership is to be implemented along with error reporting by the nurses are to be promoted without fear. Moreover, IT staffs are to be recruited to ensure proper management of ADC medicine management to avoid error along with offering training and education to nurses to ensure they create less error in providing medicine to the patients.

3. Study Stage

In the Study stage, Kotter’s 7th step of the change model is implemented. Thus, on the basis of agreed aim to test the change data regarding the test is gathered. The data was gathered by drawing information from the feedback form of the patients, managing chart review and through observation of medicine error over a period of three months. The analysis of the gathered data-informed that medication error has considerably decreased. Moreover, it was also seen that the nurses have developed knowledge and skills to administer the right medication to specific patients. However, it was seen that the wrong time and the wrong dose of medicine that was previously also creating error remained unchanged. This is mainly found to be due to lack of proper communication between nurses during shift change, improper information storage regarding patients in managing ADC and forgetting to manage medicine register and hand it over to the next nurse in the next shift.

4. Act Stage

In this stage, actions are executed to make changes in the change model for its final implementation to resolve the encountered problems (Jhonson et al. 2011). It also included last step of the Kotter’s model where institutionalisation of new approaches is mentioned to make effective change. In relation to the identified problems, effort was implemented to resolve them. Thus, communication training was established between nurses to ensure they are able to make the effective communication. Moreover, the nurses are offered training regarding the way they are to manage proper time and dose of medication to reduce the overall medicine error encountered in the mental inpatient units. Further, better management of ADC for medicine is to be organised along with ensuring right information storage regarding patients in the ADC to ensure lowering medicine errors.

Reflection

The reflection is important as it helps to enhance professional as well as personal development by raising self-awareness because during reflection the strength and weakness of the individuals are effectively identified (Marrocco et al. 2019). In this literature review study, the Driscoll Reflection model is to be used for reflecting and identifying the problems faced in implementing the change along with the action that I will take to resolve the problems in future. The Driscoll Model of reflection include three stages that are what?; so what? and Now what?. The “what” stage informs to provide description of the event (Harrison-White and King, 2015). In this study, I identified the proposed change to be made for avoiding and preventing medication error in the mental inpatient units. This is because such error leads to inappropriate care and deteriorated health outcome of the patients as well as hinders the care quality resulting in poor satisfaction of the patients from the nature of care offered to them. During the implementation of the change, I found that many of the nurses are not aware of the extent of negative impact on the health of the patients in the mental inpatient units have been created due to medication errors. This acted as problem in implementing the proposed change as the nurses showed lack of competence to the change as they felt it is not required. The other problem being faced during the change is that the nurses are not aware of the concept and way to use automatic dispensing cabinet (ADC) for the medicine to avoid medication error among patients. The knowledge regarding the proper management of ADC is required so the nurses can have access to proper medication for specified patients along with understanding the dose and administration way of providing it (Cottney; 2014). Further, I also found that few of the nurses are irresponsible in managing proper medicine register for the patients and handing them over to the nurses in the next shift to ensure avoiding medication error as most of them were tired due to overload of work. The management of proper medicine register for patients required to be shared during alteration of shifts so that the new nurse in the shift have knowledge regarding what further medicines are to be provided to the existing patients without creating any nature of medicine errors (Farag et al. 2017). During the course of implementing change, I found that the nurses lack effective education and training regarding the way to perfectly administer exact dose of few vital medicines that have resulted to raise concerned medication error among patients in the mental inpatient units. The “so what?” stage informs to analyse the event (Takase et al. 2015). On analysing the event of implementing the proposed change, I found that better awareness actions are to be taken to ensure nurses have knowledge regarding the vital negative impact of medication errors. This is because it will help the nurses to understand how the responsibility of providing the right medicine is important for them. Further, analysis of the event mentioned that nurses due to stress and workload are avoiding managing proper medicine registers for each patient because they are finding lack of zeal and energy to work properly in managing the register. I also identified through analysis that training and education regarding medication administration is important for nurses as without it a proper dose of medicine cannot be provided to the patients by them as prescribed raising medicine error. I also understood from the analysis that effective actions are required to provide relief to the nurses from extra workload so that out of work pressure they do not make medication error. The “now what?” section informs about the things to be done differently in future (Hardacre and Hayes, 2016). In future, I am going to ensure that while making any nature of change the individuals whose support is required to make the change are to be thoroughly informed about the vital need of creating change. This is because it would help me develop awareness among them regarding why the change is important to be made. In this case, in future, I am initially going to share with the nurses regarding the need of resolving medication error by highlighting the impact of the error that are faced by the patients to make them develop proper concern to be attentive to understand the need of change being proposed. Moreover, in future I am going to identify at first the nature of training and education as per the proposed change related to medication error is required by the nurses in mental inpatient units. These future steps are going to help me become a better practitioner in the sense that I would be knowledgeable regarding the way medication error of any nature can be avoided for patients accessing care in mental inpatient units.

Conclusion

The above discussion informs that medication error is a nature of preventable action which may result or orient to create inappropriate medicine use for patients bringing harm to them. This nature of the error in mental inpatient units leads to disrupt the proper management of psychological and emotional balance of the patients to improve their health. The causes of medication error in mental inpatient units includes confusion between medicine names of similar nature of two patients among the nurses, illegible written communication between nurse and health professional, lack of proper instruction to the nurses regarding the way they are to offer medication to mentally-ill patients, proper training and familiarity of medicine, inappropriate monitoring of patients and others. The impact of medicine error in mental inpatient units are mild but few are severe that is able to cause death of patients. The strategies inform that proper following proper medication reconciliation process, double checking each procedure, considering name alert, documenting everything and others are ways to resolve medicine error. However, my proposed change include implementation of the automatic dispensing cabinet for medicine, proper management of medicine register of patients by nurses, effective knowledge of providing proper dose of medicine and sharing information to reduce and prevent medicine errors in mental inpatient units. The PDSA model along with Kotter’s change model is to be used in establishing the change.

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