Improving Medication Safety in an Inpatient Setting
Creators: name: Lee, Jessica Pei-Chieh
Publisher: name: Zenodo
Year: 2018

description: At a community hospital in Southern California, medications were administered 168,117 times in 2016. Only 25 medication administration errors were reported with only five errors reported by nurses. The five reporting nurses did so due to patients experiencing problems/adverse reactions. Interviews with nurses indicated that they perceived the reporting process as burdensome and time-consuming. This situation suggests under-reporting of medication errors, in particular, near miss errors. Medication errors are also monitored closely by The Joint Commission (TJC), the State of California, and the Centers for Medicare and Medicaid (CMS), so active reporting and monitoring is essential for successful accreditation by TJC and compliance with State and Federal requirements. The purpose of this project is to improve the hospital’s medication error reporting process in order to enhance reporting of all types of medication errors. The following objectives guided the work: (a) refine medication error reporting processes; (b) educate nurses and pharmacists regarding medication error definitions and reporting criteria; (c) develop strategies to address reporting accountability for medication errors made by nurses; (d) evaluate nurse response to the changes and (e) monitor reporting medication errors. A literature search supported introduction of three interventions that might improve hospital medication safety. The first is to implement education and training to iv bridge knowledge gaps related to a standardized medication error reporting protocol. The second is to improve the logistics and rationale of the reporting system to reduce staff burden. Last is to improve feedback such that nurses are aware of changes made that aim at error resolution. All activities should be done within a non-punitive environment where nurses understand the meaning of reporting to promote patient safety and are not afraid of individual blame. Framed in an adapted Safety Action and Information Feedback from Incident Reporting (SAIFIR) framework (Benn et al., 2009), this project proposed to pilot changes on a 62-bed medical-surgical/telemetry unit where 50% of the nursing staff (40 nurses) has less than three years of acute hospital experience. In this ongoing project, policies were reviewed, revised and approved in November 2018. A 4-week staff education program was held during February 2018 along with education for new staff hires with emphasis of a no individual blame culture. The Verge Solution incident reporting software reference guide was developed to assist staff to reduce reporting time. The reference guide was introduced to staff and made available in the unit’s resource binder. The audit tool was reviewed and revised with input from charge nurses. The audit was implemented starting in February 2018. The strategies to enhance communication to nurses about medication errors and changes in policies or procedures began with daily huddles on the pilot unit; nurses were receptive to this. The generic email acknowledgment to staff that will be sent once an incident report is received was approved by the CNO in January 2018. Critical to this project has been direct involvement with the director of pharmacy, who is accountable for medication error reporting for the hospital. v This quality improvement project is ongoing, and no results are available as of completion of this project. This project requires continuous monitoring using the metrics in the evaluation plan, with revisions of the process as needed. The project lead will informally collect staff feedback regarding the medication error reporting process. The plan is that the project lead and DoP will meet bi-weekly and as needed to review medication error reports. The project lead will analyze the AHRQ Patient Safety Culture survey results collected during the August 2018 skills fair. The 2018 results will be compared to those from 2016 and 2017 to identify changes in staff perception of medication safety; specifically, whether they perceived receipt of feedback about changes put into place based on event reports and being informed about errors that happen on their unit. Medication errors can happen at any step during the medication administration process. This project translates evidence-based strategies for enhancing medication error reporting in hospital nursing practice and demonstrates the necessary collaboration across disciplines when medication error reporting changes are made. Improving medication safety will not only assist in reducing errors but, more importantly, will create staff awareness necessary to provide safe care.