4: Investigating a Critical Practice Question Through a Literature Review

Introduction

All advanced practice nurses, including clinical nurse specialists (CNSs), are often
required to partake in patient outcomes and nursing care improvement initiatives by designing
clinical practice settings that reflect evidence-based interventions and practices. Therefore,
clinical nurse specialists need to have the skills to synthesize and assess outcomes on issues
linked with nursing care and patient outcomes. A better way of achieving this is through
literature synthesis, which can assist in answering clinical questions for practice implementation.
The synthesis of the literature serves more than summarizing and documenting the relevant
literature. It is intended to yield detailed analyses and provide conclusions about knowledge gaps
and the current state of science about the subject of interest. The synthesis must also demonstrate
a clear connection between the practice issue that informs the clinical question and existing
evidence and should clarify the need for a practice change initiative.
This specific literature synthesis digests and summarizes the literature (a total of ten
articles) related to medical errors that can help answer the clinical question: “What can be done
to reduce medical/surgical errors?” The paper will demonstrate clear connections between
medical/surgical errors and evidence and clarify the need for a practice change initiative focusing
on patient safety and quality of care improvement.
Summary

A. Critical Synthesis and Assessment of the Search Outcomes
In the U.S. and other parts of the world, the problem of medical/surgical errors has
become widespread. It has been associated with multiple factors, including administrative-related

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causes like failure to provide standard prescribing procedures and provider-related reasons, such
as inadequate training. Equally, evidence has linked the surge in medical/surgical errors to
several iatrogenic adverse patient health outcomes, including increased mortality rates, hospital
stays, and cost of care. Equally, new interventions have been developed to address specific
sources of medical and surgical errors. The following part synthesizes the literature on
medication errors, their causes, potential impacts, and solutions.
Medical errors are preventable events stemming from interactions taking place in
healthcare environments, irrespective of whether these linkages harm patients or not. According
to Ahmed et al. (2019), medical errors (M.E.s) stem from failures to meet planned actions
(blunders in execution) or employing wrong interventions or care plans to achieve specific goals
(planning mistakes). M.E.s also include unintentional actions (omission or commission) or
actions that fail to attain planned outcomes. Although medical errors are inevitable in clinical
settings, Ahmed et al. (2019) believe that healthcare professionals and organizations are
primarily responsible for guaranteeing patient safety, reducing adverse events, and improving
treatment outcomes. Therefore, failure to ensure safety and quality of care can result in medical
errors and adverse events like disabilities, deaths, poor health outcomes, legal issues, and
increased care costs. In their literature review, Ahmed et al. (2019) established a need to explore
the sources, impacts, and potential solutions to medical errors in Kuwait.
The researchers conducted a cross-sectional study to investigate the risks of medical
errors and possible solutions using a sample of 203 healthcare professionals (HCPs) randomly
recruited from a government-sponsored tertiary hospital. The HCPs were recruited from multiple
settings and included administrators, physicians, nurses, nutritionists, radiographers,
physiotherapists, dentists, and pharmacists. Data were collected using self-administered closed-

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ended and open-ended questionnaires grouped into three parts. The first part gathered
participants’ demographic information, such as qualifications, nationality, gender, age, years of
experience, and department of practice. The second part examined the participants’ knowledge
about medical errors and requested respondents to tell whether or not they have experienced
medical errors incidents and the results. The questionnaire’s final section examined the views and
attitudes of respondents about interventions to prevent or lower medical errors.
In their outcomes, Ahmed et al. (2019) found medical errors in Kuwait to be as high as
60.3%, including life-threatening complications and adverse events (32.3%), extended hospital
stays (32.9%), and mortalities (20.9%). Familiar sources of medical errors include labeling
errors, diagnosis errors, wrong route of administration, incorrect dosage, and incomplete
instructions. The overall perceived route causes of these M.E.s include non-adherence to safety
protocols among HCPs, poor collaboration, miscommunication, inadequate training, medical
negligence, stress, absence of support systems, and high workload leading to burnout and
fatigue. Several mitigation strategies were also proposed by respondents, such as encouraging
interprofessional collaboration to better service delivery and training patients on the effect and
use of various medications. Other methods include consulting with more experienced and
qualified colleagues and encouraging staff members to espouse incident reporting when faced
with uncertainties.
In another meta-analytic study, Manias, Kusljic, & Wu (2020) also suggested using
medication reconciliation by CPOE and trained mentors, prescriber education, pharmacist
partnership, computerized medication reconciliation, and pharmacist-led medication
reconciliation as potential remedies to prescribing errors. For medication administration errors,
the researchers recommended using automated drug distribution systems and CPOEs as single

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solutions. Combined interventions were determined to be equally helpful in lowering both
administration and prescribing medication errors. The researchers found no specific answer to
reducing dispensing errors. Most of the studies were carried out at single-site healthcare
facilities, with chart reviews being the preferred data collection method. A similar survey by
Gracia, Serrano, & Garrido (2019) identified a different set of medication error risks, including
faults in routes of administration, errors in infusion rate, concentration, dilution errors, and
mistakes in antibiotic interval administration.
Other empirical studies also support Ahmed et al.’s findings, especially concerning the
causes, impacts, and preventive measures of medical and surgical errors. For example, using
Pareto diagrams to examine medication use processes, Yousef & Yousef (2017) found
prescribing medication due to poorly handwritten prescriptions constitutes 42.8% of all errors
committed. Other sources of medication errors included administration errors, dispensing errors,
and monitoring errors. Besides poor handwritten orders, other written sources of medication
errors stemmed from unnecessary decimal points, unapproved abbreviations, and incomplete,
illegible, and fuzzy metric systems. One of the proposed improvements includes automation and
technology by introducing computerized medication errors like automated drug-dispensing,
barcoding, and electronic prescribing systems.
Also, the researchers proposed strategies to encourage greater accuracy in medication
administration, training and education of nursing staff, and use of standardized general practices
and principles of medication administration via the six rights, including the proper
documentation, patient, route, time, dose, and drug. Introduction of a double-check system,
review of organizational procedures and policies, creation of a suitable work environment for
safe drug preparation, and reporting of incidences of medication errors were also suggested as

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potential solutions. Finally, Yousef & Yousef (2017) indicate that facilities should implement a
penal system for medication errors committed by healthcare providers and created a medication
safety committee at every facility.
Another cross-sectional study by Wondmieneh et al. (2020) to establish the contributing
factors to medication administration errors among nurses in tertiary hospitals in Addis Ababa,
Ethiopia, yielded similar outcomes. The hospital-based study involved 298 randomly recruited
nurses and used a self-administered checklist and survey questionnaire to collect data through
direct observation and self-reporting. Of the 98.3% (two-ninety-eight) nurses that completed the
survey, about 68.1% (203) accepted committing medication administration blunders within the
past twelve months. Some of the significant predictors of medication administration errors
factors identified included night duty shift (95% CI 1.82-13.78), interruption during drug
administration (CI 1.3-4.49), insufficient work experience (CI 1.32-31.78), absence of
medication administration guidelines and procedures (CI 1.06-4.06), and inadequate staff
training (CI 1.67-4.06). Like other researchers, Wondmieneh et al. (2020) recommended
providing ongoing training on safe medication administration, crafting medication guidelines,
creating an enabling environment, and retaining experienced staff members as crucial steps
towards enhancing the safety and quality of medication administration.
In a completely different research model designed to establish the root causes of surgical
errors, Cohen et al. (2017) examined 142 adverse medical errors recorded in the California
Department of Public Health’s (CDPH) Healthcare Quality Licensing Certification Program that
archives, follows up, and tabulates medical errors. Retention of foreign objects in surgical sites
accounted for 66.2% of surgery-related errors, while surgical burns and wrong-site patient
operations represented 7.7% and 15.5%, respectively. Other sources of surgical errors included

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operating room falls, equipment failure, and inadequate surgeon presence. The proposed
improvement plan suggested disciplinary actions against errant staff (8.3%), training regarding
standard policy (62.9%), revising existing guidelines (63.6%), and policy adherence monitoring
(90.2%).
In another cross-sectional survey, Parks-Savage et al. (2018) advocated for creating
physician resilience as part of the solution to medical malpractices and errors. In this case,
‘resilience’ implies strengthening cognitive behaviors and processes that allow people to override
the likely negative impacts of stressors or stressful conditions in the work environment, such as
burnout, long working hours, being overworked, understaffing, and low pay. Building resilience
should occur during postgraduate medical training. Other researchers like Laatikainen, Sneck, &
Turpeinen (2020) recommend that facilities espouse voluntary reporting to develop medication
safety within organizations and use real-time medical error recognition and response
mechanisms. Salar, Kiani, & Rezaee (2020) found using skilled and experienced nursing staff,
accreditation, and professional standards and cultivating interprofessional cooperation as more
effective strategies of limiting surgical and medical errors.
However, not all evidence has linked environmental factors to medical and surgical
errors. For example, a cross-sectional study by Tsiga, Panagopoulou, & Montgomery (2017) to
examine the root causes of medical errors using three self-reporting systematic Medical Error
Checklists (MECs) found no significant relationship between medical errors and
depersonalization and teamwork among both internists and pediatricians (p<0.001). However,
medical errors were directly linked with engagement (p=0.004) among surgeons. The study also
found no direct link between medical errors and working hours, clinical experience, age, and
gender. However, internal reliability coefficients were elevated for all the three checklists used,

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MEC-P, MEC-S, and MEC-I. Like most cross-sectional studies examined, Tsiga, Panagopoulou,
& Montgomery’s (2017) research was constrained by the use of self-reporting, which is a
significant source of overrepresentation and misrepresentation of preventable errors in clinical
settings.
B. Link Between Practice Problem, Evidence, and the Need for a Practice Change

Quality Improvement Initiative

The evidence synthesis has identified an endemic problem of medication errors in clinical
settings, stemming from prescribing to dispensing and administration errors (Yousef & Yousef,
2017). The most significant sources of medical errors include labeling errors, diagnosis errors,
wrong route of administration, incorrect dosage, and incomplete instructions (Ahmed et al.,
2019). The root causes of these M.E.s include non-adherence to safety protocols among HCPs,
poor collaboration, miscommunication, inadequate training, medical negligence, stress, absence
of support systems, and high workload leading to burnout and fatigue (Wondmieneh et al. 2020).
Despite the problem of medical/surgical errors being widespread, evidence suggests that
most of these medical mishaps are preventable. Typically, nurses and other providers have a
primary duty to guarantee patient safety by delivering quality services. This call-to-action
mandate makes it necessary to initiate a quality improvement program to safeguard the health
and welfare of patients. The article synthesis has proposed several mitigation strategies, such as
encouraging interprofessional collaboration to enhance service delivery and training patients on
the impacts and use of various medications. Other methods include consulting with more
experienced and qualified colleagues when faced with uncertainties and encouraging staff
members to espouse incident reporting (Ahmed et al., 2017).

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Conclusion

Article synthesis is a critical practice that requires examining and analyzing evidence
from previous empirical studies on a specific topic and noting aspects of interest. For clinicians,
article synthesis is a necessary process to address specific clinical questions and make practice
changes. In this particular synthesis, medication errors were established to be prevalent across
multiple clinical settings. The root causes of these preventable events are either administrative-
related, provider-related, or system-related. A lack of sufficient and accurate medication
prescription guidelines is a classic example of an administrative setback. At the same time,
potential impacts include mortalities, disabilities, and poor quality of life. Finally, solutions to
medication errors lie with addressing the individual root causes. For instance, this includes
employing skilled and experienced medical staff, using accredited and professional standards,
and cultivating interprofessional cooperation.

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References

Ahmed, Z., et al. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary
hospital in Kuwait. PLoS One, 14(5), e0217023. doi: 10.1371/journal.pone.0217023
Cohen, A. J., et al. (2021). Rates of serious surgical errors in California and plans to prevent
recurrence. JAMA Network Open, 4(5), e217058.
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Gracia, J. E., Serrano, R. B., & Garrido, J. F. (2019). Medication errors and drug knowledge gaps
among critical-care nurses: A mixed multi-method study. BMC Health Services
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Laatikainen, O., Sneck, S., & Turpeinen, M. (2020). The risks and outcomes resulting from
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Wondmieneh, A., et al. (2020). Medication administration errors and contributing factors among
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