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Open-System Theory Approach to Medication Administration Errors
Walden University
NURS6053, Section 11, Interprofessional Organization and Systems Leadership
December 10, 2017
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Open-System Theory Approach to Medication Administration Errors
According to Institute of Medicine’s report To Err Is Human which estimated 7,000
deaths due to medication error ("Preventing Medication Errors: A $21 Billion Opportunity,"
2012).
An adverse drug event (ADE) is defined as harm experienced by a patient as a result of
exposure to medication, and ADEs account for nearly 700,000 emergency department visits and
100,000 hospitalizations each year (U.S. Department of Health and Human Services, 2017).
Helms, Moore, and Ahmadi (2009) suggest that advance in IT improves patients’ safety by
enhancing the quality of care. Studies showed that IT improves patients’ safety through the
reduction in medication administration errors by implementing barcodes, EMR, and
computerized physician order entry (CPOE) (Helms, Moore & Ahmadi, 2009). The purpose of
this paper is to develop an open system approach to find ways to decrease the number of
medication errors, address the problem of inexperience related to patient safety, and develop
policies and procedures that will uphold the organizational mission, vision, and values.
Systems Theory
A systems theory must be in place for an organization to operate successfully. System
theories defined a “system as a set of interacting, interrelated, or interdependent elements that
work together in an environment to perform the functions that are required to achieve the
system’s aim” (Johnson, Miller, & Horowitz, 2008). System theories consist of inputs,
throughputs, outputs, cycles of events, and negative feedback. The open system theory suggests
that organizations interact with an outside environment through receiving and sending
information and knowledge (Meyer & O’Brien-Pallas, 2010).
Genesis HealthCare is an open-system organization that offers a variety of specialized
health care services. The facility, The Pines, on Eastern Shore consists of five units and provides
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a short-term rehabilitation after a hospital stay or longer-term care, specialized orthopedic
rehabilitation, ventilator care, dialysis care, Alzheimer's care and assisted/senior living services
(Genesis HealthCare, 2016). Genesis facility works together with other companies that provide
health care providers, called PAPP, for all units in the center. This coexistence with multiple
microsystems, such as PAPP, pharmacy, behavior health agency, gives a mutual clinical purpose
of providing health care for a local population (Johnson, Miller, & Horowitz, 2008).
Inputs
Inputs refer to an inflow of energy and information from an external environment (Meyer
& O’Brien-Pallas, 2010). Meyer and O’Brien-Pallas (2010) suggest that the energy may present
in the form of people, materials, and resources from other organizations. Genesis facility receives
energy input from a pharmacist, behavioral care clinicians, nearby hospital, and primary care
providers. For example, the pharmacist verifies medication orders and faxes any suggestions for
