Prevention of Medication Errors in Dialysis Units: A Comprehensive Reflective Account for Ensuring Patient Safety during Hospitalization

A reflective account on prevention of medication errors

Contents Chapter 1: Introduction .......................................................................................................... 3

Rationale of the present study ................................................................................................ 4

Structure of the report ............................................................................................................ 5

Chapter 2: Background issues .................................................................................................... 6

Prevalence of medication errors in Dialysis units .................................................................. 6

Types of medication errors .................................................................................................... 8

Deviation from the Facility Policies and Procedures ........................................................... 13

Overview about Medication errors in dialysis systems ....................................................... 14

Policies on prevention of medication errors in Dialysis units ............................................. 15

Chapter 3: Nature of Reflection ............................................................................................... 16

Reflection as a concept ........................................................................................................ 17

Few reflection models and frameworks ............................................................................... 17

Role of Critical Incident Analysis........................................................................................ 21

Selection of reflection model and its rationale .................................................................... 21

Description ....................................................................................................................... 22

Feelings ............................................................................................................................ 22

Evaluation ........................................................................................................................ 22

Analysis............................................................................................................................ 22

Conclusion ....................................................................................................................... 22

Action Plan....................................................................................................................... 22

Chapter 4: Applied reflection and Initial discussion................................................................ 22

Gibb’s reflective model for prevention of medication errors during dialysis ...................... 22

Description ....................................................................................................................... 22

Feelings ............................................................................................................................ 23

Evaluation ........................................................................................................................ 23

Analysis............................................................................................................................ 23

Conclusion ....................................................................................................................... 24

Action Plan....................................................................................................................... 24

Chapter 5: Further Discussion and Implication for practice .................................................... 24

Chapter 6: Conclusion.............................................................................................................. 26

Recommendations ................................................................................................................ 26

Conclusion ........................................................................................................................... 28

References ................................................................................ Error! Bookmark not defined.

Chapter 1: Introduction

Patient safety during hospitalisation always remains as a preliminary importance for all

healthcare professionals. Reduction of medical errors during hospitalisation is vastly

researched topics over a decade. This reflective account throws light on prevention of

medication errors in dialysis unit during patient hospitalisation. Dialyses are of two primary

kindswhich are Haemodialysis as well asperitoneal dialysis. The Haemodialysis is considered

as the most recognized type of dialysis, and it is the one a majority of the public is aware of.

During its performance, a tube is connected to a pointer (needle) in the arm of the patient,

blood then passes alongside the tube through to an outer machine that sieves it, and then it is

transferred back into the same arm through a different tube. This process is normally

conducted in3 days a week, with every singleprocesstaking approximately four hours

(Mohammad et al, 2013). On the other hand, Peritoneal dialysis entails the use of the inside

covering of the abdomen (known as the peritoneum) as the sieve, as opposed to the use of a

machine. This is because just as the kidneys, the peritoneum has thousands of minute plasma

vessels, qualifying it as a suitable filtering kit. Before the treatment is started, an opening is

made near the belly knob and a tinny tube known as catheter is inserted by the opening in the

peritoneal hole. This is then left in the place permanently. There after thesolutionis driven in

the peritoneal cavity by the catheter. As the blood runs through the plasma vessels covering

the cavity, the waste substances and excess liquid are gotten rid of from the blood and

deposited into the dialysis liquid.Soon after, the oldfluid is taken outof a containerand

substituted with newfluid. The fluidshifting typically takeshalf an hour and generally requires

to be carried out four times within 24 hours. The changing of the fluid can also be done

overnight through the use of a special machine known as a cycler while the patient is a sleep

(Gerald, 2003).

Rationale of the present study

Dialysis is a procedural process of removing waste products and extra fluid from the blood

system in situations where the kidneys have stopped functioning properly (kidney failure).

The process often entails diverting the blood to a dialysis machine for it to be eviscerated.

Generally, the kidneys sieve the blood and in the process, remove the dangerous waste

substances and the fluid that is in excess and turn them into urine for to be removed from the

body system. These waste substances and fluid if not removed can accumulate up to harmful

levels in the body, therefore if they are left unattended to, can result into a variety of nasty

symptoms and ultimately be fatal to the body (Renata, 2011). Therefore, dialysis process

filters out these waste products and solutions from the blood system before they become fatal

to the body. Kidney complications (failure of the kidney) may be a short-term problem hence

as such; dialysis process can be ceased when the kidneys recover. However, a patient with

failure of the kidney will often require a kidney transplant. Despite this, it is observed that it

is not normally possible to perform a kidney transplant process almost immediately; as a

result, dialysis process is required and recommended until such a time when an appropriate

donor kidney is available.

Haemodialysis removes small solutes such as potassium, sodium, urea, nitrogen, creatinine

etc from the patients using the system of semipermeable membrane or dialyser. Potential

medication errors that occurs during dialysis includes contamination of dialysate,

contamination of distilled water used to prepare dialysate, use of incorrect dialysate, leakage

during dialysis, poor fitting lines while performing dialysis and medication errors that arise

due to incorrect patient handling such as arteriovenous fistula, graft, or venous catheter.

(Kliger 2006) has reported hemolysis, toxin accumulation and transmission of infections due

to medication errors that are caused due to human mistakes. (Finelli et al 2002) have reported

that 80% of dialysis centres were reported to reuse dialysis membranes in order to lower the

cost of dialysis. Other vital reason for reuse of membranes is to reduce the generation of

biomedical waste. However, reuse of membranes for same patient will prevent medication

errors provided if the membrane is sterilised properly. Owing to these, the dialysis patient

safety program is a complicated matter that entails an extremely specialized dialysis

technology system, the training and turnover of staff, cost pressures, reporting of complicated

problems, oversight and regulatory guidelines, water sanitization, dialyzer reuse, medication

mistakes, patient compliance, patient training, primary health care, prevention, vascular

access, infection, site and design of dialysis units, and the increased age and comorbidities of

the population. Therefore, the patient safety and injury avoidance are very efficient and

effective when it includes every person in the healthcare delivery system. This is because, the

patients who go through dialysis treatment have a high risk of getting a healthcare-related

infection, for instance, hemodialysis sick persons are faced with a high risk of infection for

the reason that the process of hemodialysis entails regular use of catheters or the regular

insertion of needles in order to access the bloodstream. Besides, hemodialysis patients have

been observed to have weak immune systems; this increases their risk of infection, which

makes them need frequent hospitalizations and surgery whenever they may acquire an

infection (Denger, 2001).

With regards to medication error, though it has diverse differingconceptualization,

numerous explanations have been advanced by different researchers with the aim of coming

up with a clear meaning and understanding. For example, it has been described as, ‘any

preventable happening that may cause or that may result in inappropriate medication use and

harm to the sick or either of the two while the medication is under the control of a healthcare

professional, a sick person, or consumer,’ (Ginsberg, 2009). Errors arising from medication

may be associated with ‘professional practice, medication products, medication procedures,

environmental factors or systems, and might entail prescription and ordering; the dispensing

process and distribution mechanisms; preparation methods and administration systems;

labeling, packaging designs and nomenclature formula; communications systems and

education mechanisms; or the use and supervising of the treatment,’ (Ginsberg, 2009). Grave

errors from these may harm patients besides exposing the health professionals and experts to

civil liability and probable criminal prosecution. Others have also defined medication error as

“the failure to complete a planned action as intended or the use of a wrong plan to realize an

objective,” (Klimes, 2010). Medication error has also been defined as ‘a failure in the

treatment process that results in, or has the prospective of resulting in harm to the sick

person,’ (Seamas, 2009).

Structure of the report

This study is aimed to give a brief reflection about prevention of medication error in

dialysis units to ensure patient safety during hospitalisation. This paper provides clear

conclusion about background literature about medical errors that occurs during dialysis in

chapter 2, key theoretical concepts on reflection and explains various models on reflection in

chapter 3, discussion on prevention of medical errors based on Gibb’s reflection model in

chapter 4, chapter 5 deals with practical implications at the level of healthcare practitioner,

within dialysis unit and policy level. Finally, the paper concludes with the reflection of key

points that are discussed in earlier chapters and recommendations.

Chapter 2: Background issues

Prevalence of medication errors in Dialysis units

Human error combined with weak healthcare system in dialysis centres is often considered as

root cause of adverse events that occurs due to medication errors. When multiple patients are

waiting to complete dialysis during same time, there is a frequent mislabelling of membranes,

failing to match correct dialyser occurs. (Lacson et al 2006) clearly points out that reduction

of medical errors during dialysis depends upon patient number and dialysis volume relying

on hemodialysis units. Globally, the objective of drug treatment is the accomplishment of

defined therapeutic results that advance a sick person’s state and quality of life whereas at the

same time minimizing risks to the patient. This is because there exist natural dangers,

recognizedand unidentified, connected with the curative application of medication

(prescription and non-prescription) and the medicine dispensation tools. The occurrences or

dangers that come from such risk are referred to as drug misadventuring, and comprise both

adverse drug reactions (ADRs) and medication errors (Hahn, 2008). In this regard, the paper

therefore delves into the prevention of medication error in the dialysis unit, by analyzing the

available knowledge to help in the practice by the health professionals, experts, consumers

and patients. There are numerous types of medication errors that happen in dialysis units

which are dealt briefly in below sections.

According to the study by (RPA et al 2006) describes that 87% of dialysis staffs

acknowledged that mistake or error during last three months within their dialysis units. In a

retrospective study conducted by Holley et al (2006) observed 88 errors in 64,541 treatments

in four kinds of dialysis units. This reveals that there is one adverse event occurring for every

733 dialysis treatments. From the study of DeOreo (2009) reports patient falls as most

common adverse event occurring in dialysis units. Cook (2004) identified that 47% of patient

falls during dialysis. The chief reason behind such patient falls is hemodynamic shift that

occurs during dialysis and hypotension prior to dialysis procedure. Prescription errors

occurred for every 2451 dialysis treatments which are also called as errors of omission.

According to a survey conducted by RPA (2007) identified that taking 6-10 medications daily

and missing few medications while discussing with the doctor. In a survey conducted by

Pennsylvanian Patient Safety Authority reports that errors of omission accounts up for 48%

of medication errors. Studies from Heartland Kidney Network (2010) also confirm

prevalence of medication errors in dialysis units as more common errors due to omission of

medication during dialysis. Intravenous injection of heparin, in specific, both increased

dosage and omission has accounted for 11% of medication errors. Besides heparin, use of

erythropoietin, Vitamin D and other antibiotics also significantly contribute to prescription

errors and errors of omission during dialysis.

For instance, some studies entail time errors such as the medicine being given one hour prior

or one hour later than it had been prescribed for though other studies do not focus on this

aspect. The focus of medication admission error (MAE) research on the sum of errors can be

deceptive and may overrate the problem (Jean, 2010). As a result, a number of researchers

take in to account the severity of the medication errors which are considered to be of

importance from the patient’s perspective in terms of the reaction to the omission error that

occurred (World Health Organization, 2014). The result of such omissions can be grave and

devastating on the patient and even the family members, for example, a sick person was

admitted to the hospital as a result of a traffic accident. The sick individual had suffered joint

lower limb fractures;however, he was recuperating properly. Following aperiod, he suffered

cardiac arrest with signs similar to pulmonary embolus. The sick person was resuscitated in

proper to allow him to be moved to a critical Medicare unit (intensive care unit), but died

before long afterwards regardless of the intensified treatment. It was observed that on the

patient’s drug chart, the prophylactic heparin prescription injections had not signed that it was

being administered to him on several occasions as had been prescribed (World Health

Organization, 2014).Incorrect time erroris the administering to a patient a drug outside the

predefined duration from its planned administration period. This interval is to be defined by

each particular health care dialysis facility. (William 2010) observed that improper dose error

is additionallyreferred to as an over or under dose. It entails a situation where the sick person

isadministered with a dosage that is higher or lesser than the quantity instructed by the

instructor or physician of duplicate dosages to the patient that is, one or more prescription

units in addition to the ones that were prescribed.

Types of medication errors

Prescription error

This results from improper drug selection and often based on signs, contraindications, well-

known allergies, prevailing drug treatment, dose, dosage form, amount, route, drug

concentration, the rate of administering the drug, or directions for use the of a medication

product recommended or authorized by a physician, or any other valid prescriber, among

others (Mohamed, 2015). It also entails illegible prescriptions or drug orders that result into

errors and that get to reach the patient (Hahn, 2008), for instance, in a case of inappropriate

starting dosage of morphine capsules: A seventy year old male patient weighing sixty

kilograms was prescribed for slow discharge oral morphine tablets, sixty milligram to be

taken two times in a day, for sore pain. The patient had not been given opioidmedication. His

former analgesia drug was oral tramadol capsules, 50 mg taken thrice in every 24 hours.

Subsequently taking four prescribed amount of the oral morphine, it was noted that the

patient turned disorderly, hallucinating and drowsy, the patient had to be admitted to the

hospital where he stayed for six days once he received naloxone (World Health Organization,

2014)

Omission error or medicine administration error

This involves the failure of administering a prescribed dose to a sick person prior to the next

scheduled dosage, if any. However, what constitutes a medication administration errordiffers

from one study to another and situation to situation therefore making comparisons

problematic (AMCP, 2010).

For instance, some studies entail time errors such as the medicine being given one hour prior

or one hour later than it had been prescribed for though other studies do not focus on this

aspect. The focus of medication admission error (MAE) research on the sum of errors can be

deceptive and may overrate the problem (Jean, 2010). As a result, a number of researchers

take in to account the severity of the medication errors which are considered to be of

importance from the patient’s perspective in terms of the reaction to the omission error that

occurred (World Health Organization, 2014). The result of such omissions can be grave and

devastating on the patient and even the family members, for example, a sick person was

admitted to the hospital as a result of a traffic accident. The sick individual had suffered joint

lower limb fractures;however, he was recuperating properly. Following aperiod, he suffered

cardiac arrest with signs similar to pulmonary embolus. The sick person was resuscitated in

proper to allow him to be moved to a critical Medicare unit (intensive care unit), but died

before long afterwards regardless of the intensified treatment. It was observed that on the

patient’s drug chart, the prophylactic heparin prescription injections had not signed that it was

being administered to him on several occasions as had been prescribed (World Health

Organization, 2014).

Incorrect time error

This is the administering to a patient a drug outside the predefined duration from its planned

administration period. This interval is to be defined by each particular health care dialysis

facility.

Unsanctioned drug error

This is a patient is administered with a medication that is not authorized by a valid prescriber

or physician (Hahn, 2008).

Improper dose error

This is additionallyreferred to as an over or under dose. It entails a situation where the sick

person isadministered with a dosage that is higher or lesser than the quantity instructed by the

instructor or physician of duplicate dosages to the patient that is, one or more prescription

units in addition to the ones that were prescribed (William, 2010). The error has devastating

effects that can lead to death of the patient, for instance, two male adult sick persons

undergoing medication for compound myeloma were prescribed intravenous amphotericin

5mg per kg body weight being part of the anti-infective regimen. Two preparations of

amphotericin were existing in the clinical region; these consisted of the amphotericin

deoxycholate and the amphotericin, being a lipid complex. The Fungi zonewas made and

then given to the sick individualsbymedical personnel. The two consequently died of

amphotericin overdose; this was because the maximum daily prescription for Fungizone is

1.5mg per kg as opposed to what was prescribed (World Health Organization, 2014).

Incorrectdoseform error

This is the issuing of treatment productsto a sick person in a dissimilardose form than as is

prescribed by amedical doctor.

Incorrectmedicine preparation error

This is where a medication product is inaccurately formulated or prepared before it is

administered to the patient.

Incorrect administration system error

This entails the inappropriate process or the improper method when it comes to administering

of a drug to a patient.

Deteriorated drug error

This is the administration to a patient of a medicine that has reached its expiry date, or one in

which the physical or chemical dose form honesty has been corrupted.

Monitoring error

This entails the failure to appraise a recommended regimen to ensure appropriateness,

efficiency and detection of complications, or it can also entail the failure to use the suitable

clinical information or the relevant laboratory information for sufficient assessment of the

sick person’s reaction to the prescribed treatment. It has severe effects on the patient as

illustrated herein- A male patient was admitted to the hospital under emergency conditionfor

being toxicities with lithium. Regrettably, theplasma lithium standards were not as they ought

to be. The latestdegreedocumented, that is five months prior, was noted to be in the curative

series, as a result, his oral lithium recommendation was re-certified. His two latest outpatient

appointments had been cancelled hence his lithium levels had not been frequently monitored.

This led to the patient being ventilated (World Health Organization, 2014).

Compliance error

This entails the inappropriate behavior of the patient with regards to the adherence to a

recommended medication treatment.

Dispensing errors

This error is equally dangerous to the patient and often with devastating

consequences to the family members of the patients such as the pain of losing a loved one.

(World Health Organization,2014).

Blood Administration Error

This is a differentkindoftreatmentfault. It is noted that when administering the blood products

into a dialysis set up, exceptional care must be taken into account, that is, firstly, the

physician or the legitimate prescriber's instructions must be precisely made known to the

plasma bank and the sick person's agreement duly attained. The facility's programs and

processes are then correctly followed to ensure the accurate identification of the sick person,

the administration of the plasma products, and the monitoring of the sick prior, during, and

when the sick has received the blood. During the dialysis process, blood is often given more

speedily than in other situations, therefore, it is often very easy to miss monitor the sick's

significant signs in the course of such fast administration. To ensure that this does not occur,

proper and effective care it to be adopted to monitor the sick sufficiently during the process

of administration. The sick must also be cognizant of the symptoms associated with a blood

reaction subsequent to an administration, lastly, careful and proper documentation of the

whole process is also very vital and should be undertaken (Agrawal, 2009).

Medical Record Errors

Medical record errors as a type of treatmentfaultstake place in a number ofmodes. For

instance, the dialysis system, the physical position of the sick person’s chart, and the

treatment flow sheet may at times not be put next to the sick person. It is noted that in various

dialysis facilities, it is only the clipboard bearing the medication flow sheet that is located at

the chair next to the sick person, this contradicts the requirements that all the necessary

significant information relating to the patient’s history of allergies, the state of co-morbid,

treatments, dialysis prescription, are to be readily availed to the health care providers since

the failure to rely on such information such as on allergies can be very detrimental to the

patient (Coggins, 2015).

The dialysis system operators should therefore ensure that the dialysis facility treatment flow

sheets are regularly updated to see into it that all the vital and relevant information is

included.

Where appropriate, technological developments should be encouraged in the sector to come

up with computerized treatment flow sheets to help reduce if not limit medication errors

associated with medical record errors. Despite this, it is important not to become excessively

reliant on the computerized generated documentation, while at the same time endeavor to

ensure that the computer system is up to date with its data. This is because, it is noted that a

survey of the dialysis facilities systems computer network revealed quite a number of flow

sheets which lacked the necessary key information needed to be provided to the care givers

(Kliger, 2006). The computer handler must input the suitable and necessary data into the

computer to give a complete and necessary record of the patient to ensure proper treatment.

The computer operator should also evade the pitfall that occurs as a result of relying on a

false sense of security that is developed when using the computerized documented patient

sheets. Medical record faults are also envisaged when it comes to the handwritten treatment

flow sheets of the patients. The handwritten flow sheets comes with several problems such as

some being very complex in reading, not only do the members staff in a dialysis have

differing standards of handwriting skills but also the employment of unidentifiable

shortenings which only escalates the probability of errors as nearly all dialysis facility staff

workers have the prospective for messy writing (Coggins,2015). For instance, physicians

have habitually been ridiculed for their illegible handwriting.

Similar Patient Names

As a medication error, circumstances where the patients have the same or similar names are a

very common occurrence in the dialysis facility set up. It is advanced that even different

names but with the same rhyme in most cases is always very confusing (Coggins, 2015).

For instance, the dialysis staff members and physicians may be conversing a particular sick

person while using a different patient’s name, therefore, to avoid medication error arising

from similar name incidences, it is vital to make it clear the particular patient that is being

referred to, specifically when physicians’ instructions are being administered (Coggins,

2015). This can be realized through proper cooperation and coordination between the

members of staff, besides, the management system of the dialysis facility should employ

some unique method of like name alert system to assist in identification errors hence limit on

medication errors especially in situations where the dialysis unit reuses dialyzers.

Deviation from the Facility Policies and Procedures

This type of medication error arises where a staff member to the dialysis system unit operates

in violation of the prescribed policies and procedures laid down for the protection of the

dialysis facility system. Such actions have the potential of putting the patients, the staff

member, the entire dialysis facility, and most probably the corporation at huge liability risks

as well as dangers to their safety and life. To this end, the significance of abiding by the laid

down policies and procedures of the dialysis system cannot be over emphasized. For instance,

it is noted in the Medicare Conditions for Coverage in the United States, according to Kliger

(2006), that the dialysis facility system has written policies, established and sanctioned by the

governing organ, with regards to the conducting of dialysis and other related services to the

patients. The managing body evaluates the implementation of the policies after a given time

frame to ensure that the objective of the policies is adhered to and carried out effectively and

efficiently.

The advancementof the plansis tasked on the medical doctor responsiblefor the

administrationand guiding the issuance of the dialysis procedures. However, this can also be

carried out by the dialysis facility’s organized health professional staff in case the facility has

one, but subject to the advice of a set of professional persons associated with the dialysis

facility, who include, but not restricted to, a single or several doctors, and one or a number of

registered nurses with the relevant experience in offering services in dialysis care unit

(Agrawal, 2009). The set of professionals also conduct review of those policies in a given

time frame, for instance, at least once in every year. Under such circumstances, the physician

to be the director of thedialysis facility system is designated on paper by the management

organ to be in charge and responsible for the implementation of patients’ health care policies.

It is also advanced that in the event that the responsibility for the daily accomplishment of the

patients’ health care policies are to be or are reassigned by the physician in charge to a

registered nurse, or to another licensed health practitioner, the physician in charge must see to

it that as the director who bears the ultimate responsibility for all the happenings in the

dialysis unit, he or she provides the necessary and relevant medical guidance under such

circumstances to limit the medication errors that might result from any deviation from the

laid down requirements by the person so the duty is so reassigned.

Overview about Medication errors in dialysis systems

Medication errors are grave public health problems that threaten the safety of patients. It is

observed that in the 1950s, medication errors were taken to be the consequence of the modern

diagnosis and treatment. However, over the subsequent decades, medication errors have risen

to epidemic levels, and presently they are regarded as the third primary cause of death

globally (Evans & Swan, 2015). Of interest to note is that those bestowed with leadership

roles claim that error reduction is very complex because of the intricate nature of healthcare

facilities, especially the dialysis unit system, and the fact that the patients are often very sick.

Therefore, the growing awareness of medication error demands an improvement in populace

comprehension of the challenge and in coming up with efficient and effective solutions and

inhibition strategies to make the entire health care system safer (Evans & Swan, 2015).

With the developments in the sphere of medicine cum new drugs to cure diseases,

each medication given in the dialysis system comes with it the prospective for human errors.

To help conceptualize this, it is of importance to assess the five rights fundamentals of

medication administration that the health professionals and experts are equipped with in the

initial stages in medication administration training. These are the correct sick person, the

correct time frame, the correct medicine, the correct dose and finally the correct course

(Kliger, 2006). Treatment errors can occur in the event that one or a number of these ‘rights’

are not observed. However being a place to start, the knowing and usage of these five rights

is not a guarantee of preventing all medication errors, the scenario is further complicated by

the fact that several medications are packaged in the same way, as a result, any medication

prescription can be misconstrued or administered to the wrong patient. In addition to these,

non-licensed staff members of a facility do administer routine drugs such as Heparin among

others in the dialysis systems.

It is also observed that agency based dialysis health professionals and experts are at

times utilized to sustain staffing ratios in the dialysis units. Of concern is that these

provisional staff professionals and experts may not be in a position to identify the sick or be

acquainted with the dialysis facility procedures. This is because as opposed to the hospital

set up, the dialysis sick persons in the outpatient division do not put on name brand

identification rings, as a result of this, a number of medication errors have occurred in good

dialysis units (Kliger, 2006). For instance, some sick individuals have been given Hepatitis B

inoculation intravenously as opposed to being inculcated intramuscularly. Similarly, some

patients have also been easily administered with overdoses of Heparin. It is also advanced

that severe reactions have taken place in patients resulting from administration of iron. This

has occurred because of the improper administration of antibiotics on patients (Kliger, 2006).

To salvage this, giving out of antibiotics must be watchfully carried out as some sick persons

can have several medication hypersensitivities. To guarantee this, cautious thought should be

given to the wrapping, storage and giving out of medications. For example, Heparin has

always been mistaken to be Lidocaine and Lidocaine to be Heparin, this is because all are

clear solutions and may be put in like bottles.

It is also observed that purchase of goods with like packaging mightalsobe a probable

reason of medication error. Nevertheless, some corporate procuring agreements limit the

number of available sellers. It is therefore advanced that in the event that similar packaging

is inevitable, then one should endeavor to keep medications in different positions or in the

alternative, draw further difference to the medication by the use of intensely colored stickers

or other appropriate methods of alert. The labeling of treatment syringes is vital the failure of

which is a serious cause of medication error. This entails proper indication of the appellation

of the drug, the proper dosage prescription, time, date, and the name of the patient (Russell et

al. 2007). Labels are available to assist the staff members in a dialysis unit in quick

preparation of syringes.

Policies on prevention of medication errors in Dialysis units

Dialysis units are operated under many regulatory bodies concerning the patient safety as

chief responsibility. The below table describes the role of various policy makers on regulating

patient safety during dialysis.

Centers for Medicare & Medicaid Services Specific quality indicator

Association for the Advancement of Medical

Instrumentation (AAMI)

Sets standards for water quality, dialysate, and

reuse procedures.

Surveyors from State Department of Health Can close units that do not meet standards of

care.

End-Stage Renal Disease (ESRD) Networks Responsible for quality assurance and

improvement in dialysis facilities within the

network. Medical directors are given periodic

assessments of unit morbidity and mortality

compiled by the networks through CMS.

Centers for Disease Control and Prevention

(CDC)

Sets standards for infection control in dialysis

units and provides standards for indwelling

catheter-associated infections

United States Renal Data System (USRDS) A repository of data collected on each chronic

dialysis patient covered under Medicare. An

annual yearly report is published including

special studies examining morbidity and

mortality of dialysis. Data provided by USRDS

may determine ESRD Network quality

improvement projects and lead to development of

standards of care.

According to CMS (2008) emphasises that medical coverage for dialysis units includes

measuring the quality of each dialysis facility offered by centres, analyse and track all the

necessary quality indicators of facilities and process of medical care given to the patients.

Every dialysis centres must comply all quality indicators in order to receive Medicare bills.

AAMI has set few standards for dialysate and water. Also, CDC has set few guidelines for

reducing infections during the process of dialysis and reuse of dialysis membranes. Director

is responsible for routine monitoring of these safety standards within dialysis centres to

ensure patient safety. State department of health surveyors has authority to close the dialysis

centres which lack certain compliance standards to prevent medication errors and ensure

patient safety during dialysis.

CMS regulations clearly depicts about patient and facility safety at dialysis units. These are

addressed as integral components of QAPI process. Dialysis units should create a safety

team. This team must put effort and improve safety by ad hoc efforts. Since the attitude

regarding safety might differ, it is valuable to dispatch questionnaires on patient and facilities

safety which is conducted by ESRD networks. It is possible for such teams to evaluate safety

risks such as medication errors; access complications etc. and improve strategies to reduce

medication errors during dialysis

Chapter 3: Nature of Reflection

Reflection as a concept

According to scientific terms, reflection means light and heat. Reflection is also seen in terms

of gaining knowledge via practical experience, learning and applying various approaches to

same scenario (Chambers et al 2012). Theorist John Dewey has described reflection as

persistent and active thinking mechanism. Such thinking mechanism is supported by strong

evidences to form knowledge over situation. According to (Bulman and Schultz 2008) entails

that an individual uses their mind and emotions to facilitate reflection. (Vachon and Leblanc

2011) suggests that Dewey describes reflective individuals are generally open minded and

experienced on their concepts. Johns and Freshwater (2005) also explains that medical care

professionals should find the real meaning of reflection by defining the concepts clearly and

describing the real situations behind the concepts. Various reflective theories and models are

used to understand the reflection by holistic approach which can be subjective and purpose

driven. According to Mann et al (2007) describes that reflection can happen in two different

ways based on perceptions of Schon namely present reflection and past reflection. Reflecting

on present means reflecting on current activities and past reflection is defined as reflecting on

events that occurred in the past.

Few reflection models and frameworks

Reflection model that is developed by Schon and Argyis (1992) stresses that reflection

consists of three fundamental elements namely 1) Knowing in action 2) reflection in action

and reflection on practice. According to studies from Ghaye and Lillyman (2010) have

further explained Schon’s concept on reflection especially knowing in action. It was proposed

that medical care practitioners should customise and tailor their knowledge by developing

new theories based on their practical experience. Also (Newton and McKenna 2009) explains

that there are four fundamental concepts in knowing in action such as empirical, personal,

ethical and aesthetic knowing.

Reflection in action concept developed by Schon and Argyris (1992) has been adjusted from

Schon (1983) it is to do with reflecting at the time without irritating consideration. It includes

considering 'on your feet' Ghaye and Lillyman (2010) suggest that whilst this might be an

intricate procedure it is by a wide margin the best when elucidating that necessities of

patients are being met. It is the route in which professionals make themselves to handle and

resolve troublesome circumstances while being confronted with them (Schon 1992). This

could involve considering what should be said to patients whilst conversing with them as of

now. Gustafsson and Fagerberg (2004) state that Schon (1983) trusts appearance in real life

permits medical caretakers to show a joined scope of aptitudes - theoretical learning and

clinical experience. This kind of reflection is hard to ace as is test our knowing-in real life

and is utilized by expert specialists that have gained specialized aptitudes over various years

Rolfe et al (2011) and Ghaye and Lillyman (2010). Mann et al (2007) state that proficient

experts can reflect-in real life since they have the information to do 'interpretive introduction'

- observing, surveying and changing patient consideration on a persistent premise. Mann et al

(2007) likewise express that understudy attendants are constrained to appearance in real life

in light of the fact that their encounters are not genuine and the part is managed all through in

this way understudies activities are addressed and changed if important to suit understanding

consideration. This is the reason basic reflection is critical learning apparatus for understudies

and can be encouraged by coaches, clinical chiefs.

Schon (1992) reflection-on-activity is pondering back occasions occurred. The reflector can

inspect and dissect the occasions orderly either inside self, talk with another professional or

inside gatherings (Ghaye and Lillyman 2010). Greenwood (1998) make on reflection on

move as 'intellectual posthumous' this is the place the expert retreats to survey activities that

were made amid the occasions. Greenwood (1998) contends that reflection before activity is

not regarded essential for this sort of reflection and to be not able reflect before activity is

viewed as incorrect as patient consideration and results get to be affected by these elements.

It is as of now realized that Dewey was the primary supporter of learning by reflection, Rolfe

et al (2011) compress Dewey's (1938) model of intelligent learning as encountering through

watching and thinking about present or past occasions which prompts increasing new or

upgrading information. In present day human services however Gibbs (1988) model of

reflection see informative supplement 1 is broadly utilized which is an adjustment of Dewey's

(1938) unique model. Gibbs (1988) model requests that the expert illustrate the occasion -

portray what happened and join feelings and contemplations to the occasion. Gibbs then

prompts the expert to weight what was great or awful about the experience. The third part of

the model is specialized this part requests that the professional break down the circumstance

in the want to reveal either new discoveries or affirm the present circumstance. The fourth

viewpoint is about comprehension and discovering what else could the expert have done to

change the past result of the circumstance being begun and finally the specialist is provoked

to compose an activity arrangement on the off chance that the same or comparable situation

can take it our (McKinnon 2004). In spite of the fact that Gibbs model seems patterned it is

not clear in the matter of how the activity arrangement which finishes up the reflection

procedure is connected back to portrayal (Rolfe et al 2011). Gibbs model of reflection give

the professional basic and general prompt inquiries which permits the specialist space to

extend their considerations on additionally it the most broadly utilized reflection model for

understudy medical attendants (Bulman and Schutz 2009) conversely Rolfe et al 2011 state

that Gibbs model has a non-specific and unspecific feel in this way some intelligent experts

discover Gibbs model to dubious.

Holms and Stephenson (1994 see additionally Rolfe et al 2011) proposed another reflection

system comprising of better composed sign inquiries. Stephenson structure is pointed towards

more on activity instead of conjecturing results. Rolfe et al (2011) propose that Stephenson

and Holms system mirrors Dewey's underlying understanding of learning by considering.

However neither one of the gibbses model or Stephenson system incorporate an unmistakable

rule to how learning can be connected to rehearse separated from getting some information

about what they would in the event that they experienced a comparable circumstance once

more.

The structure set out by Johns (2004) is an adjustment of numerous systems and models by

numerous creators (Johns and Freshwater 2005). John and Freshwater (2005) included not

just the diverse parts of reflection such in real life and on-activity additionally careful

practice. Benner et al (1996) clarifies that careful practice is seen as clinical judgment which

is experts having the capacity to see what is going on as it incident in a clinical domain that

permits the specialist to draw in morally with the circumstance. Johns (1995) structure

additionally included reflexivity which requests that the expert return to the circumstance and

asks interpersonal inquiries that permit the specialist to connect past encounters to the present

circumstance. Johns and Freshwater (2005) see supplement 3 have figured out how to

verbalize a model of reflection which is organized and compact this model likewise affects

clinical supervision and can be utilized for coaching purposes.

Taylor (2006) delineates his model of reflection by utilizing the words REFLECT as mental

helper where every letter is speaks to a procedure of how reflection can happen. Implicit

learning is shown in this kind of reflection, it is information that specialists are unconscious

of having and just becomes exposed when reflecting about the choices they have made either

amid or after the occasion Schon (1987). There is a feeling of freedom joined to Taylor's

appearance as it likewise brought on the professional to acknowledge of news thoughts and

not to be limited to imperatives Taylor (2006) utilizes a basic companion to energize

reflection. Taylor (2006) comprehends that adjustments in mindfulness is a certain

probability in light of the fact that new bits of knowledge can emerge through reflection this

happens by connecting feelings and emotions moreover it asks for the specialist to ask

themselves what have they learnt from their experience. Taylor model of reflection is laid out

in way that requests organized basic reflection and requires a facilitator or basic companion

to see the procedure through this could be a detriment since it can be a requesting strategy,

not extremely engaging to test top positioning staff and a facilitator may not be accessible

(Rolfe et al 2011).

Kolb (1984) and Rolfe et al (2011) model of reflection is coordinated towards trial learning,

Kolb model is set out such that it requests that the specialist look past depicting and seeing

past occasions additionally to hypothesize on the intelligent occasions to figure out whether

new methodologies can be tended to or actualized. Kolb's exemplary model of trial learning

comprises of four segments; experience, perception/reflection, speculation and

conceptualisation and dynamic experimentation (Stonehouse 2011). At the point when

contrasted with Gibbs demonstrate this model is really recurrent and reflexive in light of the

fact that Kolb embarks to create a speculation to test the clinical setting thus the specialist is

permitted to restore pondering the recently changed experience (Rolfe et al 2011).

Significance of reflective practice

Reflective practice is seen has utilizing intelligent methods to enhance, keep up changes in

clinical strategies and impact rules to support more prominent security of patients in every

aspect of healthcare associations (Bulman and Schutz 2008). Duffy (2007) states reflective

practice should unmistakably be shown by the expert for individual and expert advancement

in nursing and other unified wellbeing callings.

Price(2004) states that nursing practices can be changed by encouraging knowledge and

reason by specialists, Price (2004) likewise comprehends that workforces may likewise be

dubious of the insight behind changes to specific techniques for instance changes to

multidisciplinary group gatherings held as a rule midweek could be changed to a day nearer

to the weekend and accordingly the workforce might be far-fetched of referrals being gotten

on time to their pertinent accomplices. Blazes and Bulman (2000) and Johns (2000) declare

that intelligent practice whilst it understands focused all addresses the untidiness and disarray

of the clinical environment.

Benner et al (1996) includes working of the practice environment is not as obvious as a

science course book. Johns (2005) states that adapting however reflection prompts edification

- discovering who we are, strengthening - having valor to reclassify who we are and

liberation - offered opportunity to roll out improvements to accomplish alluring impacts. It is

the part of clinical directors, preceptors and guides to empower and execute reflection and

basic speculation inside their practice surroundings (Cost 2004). Reed (2008) state that

coaches can bolster less experienced or new representatives by imparting their experience to

them and giving a larger amount of information and comprehension of various work hones.

Duffy (2007) utilizes Williams (2001) to recommend issue based learning gives boost to

understudy medical caretakers to build up their basic reflection aptitudes.

Role of Critical Incident Analysis

Reflection practice is conveyed when undertaking basic occurrence investigation (CIA).

Basic episodes can be either an amazement occasion (ref) or arrangement of occasions that

could trigger reflection (Hanning 2001). The investigation procedure empowers the

professional to stop and consider on the circumstance and to build up intending to the

circumstance. Basic intuition can be seen as either negative or positive encounters (Cost

2004) and along these lines a few experts have shown distress connected with basic

occurrence investigation in light of the fact that the procedure can challenge what they

thought they knew as well as can be expected have undesirable impacts and inspire outrage,

sorrow, disappointment and misery (Rich and Parker 1995 see additionally Vachon and

LeBlanc 2011). Basic occurrence occasions could be seen as medication mistakes,

nosocomial cross-contamination or helping a patient accomplish an agreeable, stately

passing, shutting of wards. However not all occurrences must be as grave as these. CIA can

likewise be seen as a critical occurrence where it doesn't posture prompt risk, notwithstanding

it causes the professional to reflect upon the circumstance in orderly way (Ghaye and

Lillyman 2010).

Selection of reflection model and its rationale

The present study chose Gibb’s reflective cycle (1988) to reflect on prevention of medication

errors during dialysis. This is a very famous model for reflection. This model consists of six

important stages. They are description, feelings, evaluation, analysis, conclusion and finally

development of action plan.

Description

In this section, the background information about the problem and the basic reason for

reflecting the problem should be explained to the readers.

Feelings

This specific section explains the personal feelings to the readers. This section explains how

do you feel about the problem and what is the post incidental thinking of yours. This explains

a general attitude towards the problem.

Evaluation

This section describes how the reflector deals with the problem which is reflected. The way

attempted for reflection is also explained. Few good and bad experiences were also shared by

the reflector to the readers.

Analysis

Analysis section can be explained with prior literature on observed research problem. This

section compares the current reflection with earlier literature and theories.

Conclusion

Conclusion part acknowledges whether any further development can be done for the observed

research problem.

Action Plan

This section summarises various strategies employed for improvement of research problem,

in this case, prevention of medication errors. Besides other reflection models, this model is

beneficious in developing action plan after reflecting on the identified research problem.

Chapter 4: Applied reflection and Initial discussion

Gibb’s reflective model for prevention of medication errors during dialysis

Description

I found that there is a remarkable increase in medication errors during dialysis. All reflections

were performed based on Gibb’s reflective model. This reflective cycle commences with

description of problem, followed by explaining feelings, situation evaluation and analysis of

research problem, conclusion and providing an action plan. Reflection will provide self-

confidence. One of the most important activities during nursing practice is when I gather

information about administration of medications for dialysis patients in my dialysis unit. I

gathered medication information based on the patients chart and medical record file. I found

that drugs charted in the file were unclear and also I can see very poor handwriting of doctor.

It was not at all legible. The exact dosage to be taken before dialysis was absent in the

medication chart. This is a kind of prescription errors and omission error where few

important information is absent which results in common medication error as discussed in

Chapter 2. Medication errors are the most predominate type of errors that occurs during

dialysis. Chief causes for medication error in healthcare system as per my reflective practice

is poor handwriting, work stress and poor documentation.

Feelings

My feeling as a nurse is to percept on the research problem which could be observed through

their experience. Identification of drug name according to the drug therapy provided to the

specific dialysis patient was little bit tough for me due to poor handwriting.

Evaluation

On evaluation, I followed my preceptor’s advice to identify the correct drug name from the

medication chart during my nursing practice. Time during the clinical practice is very

important since it is important tendency not to hold up proceedings for longer time. I become

severely anxious since I had only little understanding on the drug names that are routinely

used in the dialysis unit and this caused time delays during busiest hours in dialysis centres

which made many patients to wait for longer time. In order to reduce the waiting periods, I

had a pretty good idea for identification of drug name by discussing with senior health care

professionals in the same unit.

I made my preceptor aware that I am collecting drug information as a part of my professional

health care practice. It was my responsibility to gather correct medical information in the

entire dialysis unit. By accessing online medical drug information program, it was very easy

for me to identify the correct drug name

Analysis

Upon analysing the same drug information with pharmacist, I received accuracy on drug

information at paramount as set by standards of Renal Physicians Associations.

Conclusion

Based on the collaborative effort from preceptor, online medical databases and pharmacists, it

was simple for me to gather and correct the drug names with dosage with accuracy.

Action Plan

My future action is to avoid the occurrence of this event again which means preventing the

medication errors. For this, I must first learn all competency standards involved in reduction

of medication errors in dialysis. Also, communication is essential for reduction of medical

errors. This also requires collaborative effort from other allied health services such as

pharmacy etc. Critical thinking along with practical experience are core importance for

reduction of medication errors during dialysis.

Chapter 5: Further Discussion and Implication for practice

Medication errors, as discussed here above entail actions, deficiencies, or decisions

that if fixed, eliminated, or circumvented will do away with the detrimental consequence

associated with them. The medication errors and the factors leading to their occurrence

covers the entire health sphere, involve all the stakeholders and range human factors, patient

related issues organizational factors such as staffing, policies and management among others.

It is noted that one of the major fears of any health professional or expert is to be

involved in a medication error that can cause injuries a patient (World Health Organization,

2014). It is also noted that despite the best, and the most diligent efforts aimed at eliminating

medication errors, the errors still find their way into the dialysis systems and other health

sectors. Due tothis, there is a necessity to develop plansand mechanisms to eradicate or

minimize medication errors. To aidin achieving this, the first stage is to understand the effect

the medication errors have on the persons involved.

For instance, health professionals and experts do get tremendously concerned when a

medication error occurs; this is characterized by an exhibition of feelings of panic, fear,

defensiveness, and self-defense. These feelings can negatively affect the manner in which a

health professional or expert responds to a situation of medication error (Beth et al. 2012).

Thus, it is very vital to know how to handle the health care professionals who get involved in

a medication error, and also how the professionals or experts are to respond to such

situations. Apart from the health care professionals and experts, the patients do also, as a

result of medication errors, go through emotions, such as getting scared, confused, anxious,

or angry. Such reactions have daring consequences and therefore necessitate that they are

either minimized or eliminated. To aidinachieving this, the following plans can be utilized.

Measure should be employed to ensure that the care givers who take part in the

dialysis units operations by review and administering medications prescribed for the sick

include the drugs that the sick receive during the entire dialysis medication in the reviews.

(Pennsylvania Patient Safety Advisory, 2010); treatment procedures to be simplified, such as

the timing of drug administration during dialysis treatment, to help minimize the possibility

of medication omissions; the health professional and experts are encouraged to carry out

independent dual examinations of IV heparin dosages and mixtures before administration

(Silver,2009).

The governing organ and the management body should invent mechanisms to see into

it that there is a reconciliation of medicines at each and every transition point in the sick

person’s care, including but not limited to changes when the sick is transferred from a

hospice care division, for example, the medical surgical division, to the renal division for the

hemodialysis process and back.

To help achieve this, there should be clear, accurate and precise communication network

between the healthcare workers when a sick person is moved from one care division to

another (Pamela et al. 2008). The clear precise and accurate communication should entail the

use of unambiguous language to give the latest facts about the sick person’s care, medication

received, the sick person’s health condition, and new or predicted changes. The medical

treatment giver who receives the information should reiteratetheparticularsfor certification

and ask questions to shed light on the unclear details or instructions.

The dialysis patients should have a list of every treatment they undergo and share the

list with the care workers in the dialysis unit and other health care facilities where the sick is

treated; the dialysis sick persons should also be educated about their treatments, and in

addition, be advised to be attentive for any possible medication errors. With regards to the

failure to observe protocol, the governing organ and the management body is to provide the

dialysis facility staff with checklists for appropriate and proper dialysis set up, the procedures

to be observed and the resulting consequences in the event that any of the provisions is not

adhered to. Such checklists should provide for double checks to ensure accuracy and

minimize the probable errors (Roy et al. 2008). The management organ should also establish

red rules with explicit provisions that must be accurately adhered to for particular set-up

procedures.

The sick in the dialysis unit should also be engaged to enable them to speak up if

anything appears amiss. For instance, a patient can speak up if the tag on the dialyzing

solution does not correspond to that in his or her prescription, or the failure to label the

dialyzer with the name of the patient.The management body ought toimplementmeasures

aimed at averting dialysismedicationconfusions of sick individuals with like names.

To realize this, the management is to develop ways of alerting the staff of the potential for

confusions, and also develop the use of two patient identifiers for the patients with like

names, for instance, the use of the sick person’s name and the sick person’s date of birth to in

verifying a sick person’s identification (Mayo Clinic, 2014).

Chapter 6: Conclusion

Recommendations

The normal norm has been that when an error occurs at any particular point in the

dialysis unit or any healthcare facility, the analysis as to why the medical error occurred

focuses on the human aspect, and concentrates on personal responsibility for causing the

error. The solutions to such an error have always entailed retraining or educating, additional

extra supervision, or in some instances, disciplinary action are taken on the individual.

Alternatively, the management body is to adopt a system-centered approach, which takes into

consideration the fact that human beings are imperfect; hence systems are to be designed such

that human beings are stopped from making errors.

The dialysis system management unit should acknowledge that human is to err, hence should

learn from the errors, and develop mechanisms to avert future errors from happening. This

will create a transformationfrom the normal blame and punishment, the examinationof the

main bases of medication errors and the employment of strategies to avertthem. With this

approach, each and every individual within the dialysis facility and other healthcare facilities

has a responsibility in making the facility a safer system for the patients, workers and all

other stakeholders.

The management is to ensure that proper care and adequate consideration is taken when

hiring and allocating persons involved in drug ordering, medication preparation, dispensing

of medicines, drug administration, and in the education of patients. To realize these, the

management is to come up with appropriate policies and techniques that ensure an adequate

employees selection, staff training and supervision, and entire evaluation process. These

entail the need to ensure appropriate and suitable interviewing mechanisms, proper

orientation, an efficient and effective competency evaluation system, strict supervision, and

availability of advancement opportunities to ensure technical education for the entire staff.

The management of a dialysis resource must guarantee that the resource has satisfactory and

competent personnel to carry out tasks sufficiently. This is to be achieved through proper

policies and techniques that see into it that rational workload standards and working durations

are established and hardly deviated from.

The dialysis unit should have proper working environ to prevent interferences in the

preparation of medication products. To see this realized, potential medication error causes

within the work location, such as regular interruptions, are to be identified and eradicated.

The dialysis unit is to see into it that pharmacists and other persons in charge of processing

medication orders have regular access to relevant medical information relating to the patients,

the information which include the patients medication, allergies history, and hypersensitivity

profiles; the diagnoses of the patients, pregnancy status and the standards of the laboratory to

help estimate the suitability of medication orders.

To further achieve this, the pharmacists are to maintain treatment profiles for all the patients

in the dialysis unit, both the inpatients and out patients. This profile is to consist of sufficient

information to enable in the monitoring of treatment histories, history of the allergies, the

diagnoses, the possible drug interactions, the occurrences of duplicate medication therapies,

applicable laboratory data, and other relevant information.

It is further recommended that the dialysis unit should have functional computerized

pharmacy systems to enable for the automatic checking of doses, history of allergies and

lastly drug interactions. Where it is possible, the management should devise mechanisms to

ensure the use of technological inventions such as bar coding to assist in identifying the

patients, medication products, and the care givers. There should also be innovations with

regards to pharmacy-generated treatment management records and labels to help the staff in

construction and documentation of medication activities.

Conclusion

From the foregoing, the protection of the patients is the foundation of valuable health care

services in a dialysis system. A vast number of patients receive dialysis in various dialysis

facilities globally and therefore, their safety, care, protection and good quality services is

ultimately the obligation of the dialysis facility governing organ, management body and the

entire staff. For instance, the governing organ in coordination with the managing body must

establish and constantly monitor a culture of safety, care, protection and good quality services

in the dialysis unit, and ensure an effective and efficient quality assessment and performance

improvement process. These are achieved by carrying out a number of lines of examination,

including assessments of the patients and dialysis professionals, which help to identify vital

areas of safety dangers in the dialysis facilities.

Amongst the areas of safety dangers in the dialysis units include lapses in communication and

communication systems, patient falls, errors in the equipment and in the preparation of

membrane, the failure to abide by the laid down policies and procedures, and lapses in the

control of infections. The quality valuation and the performance enhancement process is to

consist of a qualified, dedicated and experienced safety team which is to concentrate on

precisely identified areas of danger and to form the outcome aims guided by the best

practices and measures of success agreed upon through proper consultation and participation

by all the stakeholders in the dialysis system. The areas are properly identified through safety

questionnaire given to the patients and the staff members and the responses got from them

appraised to help in improving the understanding of the prevalent attitudes and concerns

about care, protection, good quality services and safety in the dialysis facility.

The results of such questionnaires and the assessment are shared openly and the challenges

acknowledged without blames as to the root causes to assist in identifying action plans, hence

help the dialysis facility to establish a culture of care, protection, good quality services and

safety.