System Failure

Among the many existing system failures that lead to an infant death, one of them is the lack of a unit dose system. A unit dose system in the facility is usually located in the pharmacy department. At this point, drugs are issued to patients with the help of a nurse or a pharmacist. Significant errors that occur due to lack of dose system are dispensing errors, as well as prescribing errors. While prescribing a drug to an infant, the problem is that a child might be given the incorrect drug. The wrong type of drug might be selected. The prescribed dose might be too low or high. The dosage form might be wrong, as well as the rate of administration and administering a different drug from the ordered one, as well as the quantity of drug could be incorrect. Besides, a child could be prescribed the wrong route of administration (Lavin, Harper, & Barr, 2015). All these errors may be the result of wrong prescription. Therefore, this has resulted in the lack of a unit system at the facility. Apart from that, a child could have missed a drug he/she was prescribed. It means there was an omission of medicines they were supposed to get. Again, due to lack of the dosing system, there was the wrong preparation of drug before administering it to a child. All these might have occurred due to the lack of a unit dose system at the facility.

Measures should be put to reduce the prescribing and administering errors. The administration of the healthcare system should improve the personal computers software, so that they can adapt a computerized system that is efficient. Besides, the administration should work towards designing a drug use evaluation (DUE) that will help reduce the errors that occur during drug medication (Lavin et al., 2015). At the pharmacy, where drugs are being issued, it should have qualified personnel who is an expert on drugs and has the knowledge of all drugs to avoid issuing the wrong prescription to patients.

Apart from that, the pharmacy department should provide a suitable environment for their staff. There should be a proper environment during the drug preparations. Potential errors that may occur in the workplace, such as the frequent interruption, should be minimized. The informatory system in the facility, made up of physicians, pharmacists, and nurses, must formulate the policies regarding the selection, evaluation and the therapeutic use of drugs in the health care setting. Besides, care, as well as consideration, should be communicated to the assigning and hiring personnel who are directly involved in the preparation, administering, dispensing, as well as medication ordering (Lavin et al., 2015). By so doing, it will ensure that all the personnel have knowledge of drugs and should ensure only the right drugs are in the pharmacy point. Therefore, the pharmacy department should address the issue to the department that deals with rendering drugs. Besides, the administration of health care setting should work toward improving the current systems to ensure that it has an updated structure that minimizes prescribing and administering errors.

There are some researches done on the lack of dose system that causes medication errors. One of the researchers was on investigating the causes of medication errors and the strategies put to prevent nurses from the errors. The reason for carrying the research is because medication errors can cause death. The recommendations to reduce the errors were increasing the number of training, so as the nurses and pharmacists get knowledge on the drugs to avoid administering errors. There is the need to improve the system in the facility and also avoid manual prescription, as it increases errors. Then, the number of manpower at the pharmacy should be proportional to the number of patients (Lavin et al., 2015). Therefore, this ensures that the workers are not overworked.

Another system failure that might lead to the death of an infant is staff inexperience and poor documentation. In a health care setting, staffs from different departments work synergistically. All staff members play a crucial role in achieving the quality care. Therefore, in the case of inexperienced staff, it could be from the nursing department, as well as the pharmacy department. A nurse might not be experienced in administering injections. If a drug was to be intravenous, they give intradermal. Else, an employee might be inexperienced in administering injections, thereby bringing about errors. Another error inexperienced staff might have is poor timing (Croke, 2003). They do not give a patient drugs in the expected time. Once a patient misses a dose, it means there could be an effect. Moreover, a staff might give over or under dose drug from the one prescribed. Again, if personnel are new in the department and not experienced, they could give the wrong prescription. They might omit a drug or give a patient a drug they were not supposed to get. Therefore, in most cases, inexperienced staff, either a nurse or pharmacist may end up messing up with a patient by issuing wrong drugs (Croke, 2003).

Apart from that, another problem is poor documentation. The problem is common especially in health care where documentation is manual. In facilities where they have embraced the use of technology, the problem of documentation is common that can lead to death of a patient. In places where there is no manual documentation, it reduces poor documentation. For example, a patient may come for the checkup, but the documents cannot be retrieved. In such cases, a physician may end up prescribing other treatment from the previous diagnosis. Change of diagnosis and prescription have an effect on a patient, especially where previous treatment should be procedural (Gorgich, Barfroshan, Ghoreishi, & Yaghoobi, 2015). Another effect of poor documentation is when a patient’s file document cannot be retrieved, and maybe they are supposed to get drugs, but the file cannot be found. It happens that whereby a nurse misses the document, and thereby they fail to issue drugs to patients at the right time.

Therefore, the nursing department, pharmacy, and the record department should be involved to reduce the error of inexperienced staff as well as inadequate documentation. The health facility should have electronic documentation; whereby all patients’ data should be well organized in the computer for fast as well as easy access. The manual documentation has shortcomings. For example, files may get lost, or the service provider may not retrieve the file while needed. All care providers should have a personal computer to help them retrieve a patient’s data whenever there is a need. Besides, the health records department should keep the files well locked and properly arranged for easy retrieval of files (Gorgich et al., 2015). Besides, personnel should be trained on how to store documents, record, and maintain the data.

The problem of inexperienced staff can be dealt with in various ways. First, a hospital administration should work with qualified and competent healthcare providers. Again, a trained worker must have skills and knowledge of dealing with children. Besides, the nursing department in collaboration with the administration should organize frequent training to equip staff with relevant skills. There should be rules and regulation governing all health care providers, and how they should carry out their duties. This ensures no negligence or poor performance. Everyone should be accountable for their actions (Croke, 2003). The nursing department should work in increasing the number of care providers to avoid high workload. The high workload may lead to nurses abandon some patients or miss out attending all patients.

Different researches have been done to improve documentation in the healthcare setting. According to Gorgich et al. (2015), proper documentation yields patient safety, enhance efficiency, and improves the quality of care. Therefore, the research recommends using electronic documentation for easier and fast retrieval of data. Besides, nurses should train on how to store data in an organized manner so as to access the information fast whenever in need. Besides, a hospital should focus on improving documentation and storage of a patient’s information.

Besides, researches have been done on the effect of inexperienced staff. The effects were caused by inexperienced officers to their patients. The study of malpractice and negligence among nurses shows that most patients suffer from the neglect or being attended by an underqualified nurse. It showed that most nurses are sued due to the negligence of patients or lack of proper skills to attend patients. Therefore, the research recommends periodic training of nurses to equip them with the relevant skills needed (Croke, 2003). Also, there should be more nurses who are qualified. Besides, there should be many nurses because when there is a high workload, the number of errors increases. Therefore, a hospital administration should work on employing more health care providers. Therefore, there is a need to have qualified and competent healthcare providers to avoid medical errors while dealing with patients.