Improvement Plan Tool Kit
The following tool kit is designed to provide nurses and team members with the tools they need to assist achieve and maintain safety improvements in medication administration best practices. The toolkit has been separated into four categories: staff-led strategies and best practices for reporting and enhancing environmental safety issues, general organization safety and quality best practices, and environmental safety and quality best practices.
Annotated Bibliography
General Organization Safety and Quality Best Practices
Ragau, S., Hitchcock, R., Craft, J., Christensen, M. (2018). Using the HALT model in an exploratory quality improvement initiative to reduce medication errors. British Journal of Nursing. 27 (22). 1330-1135.
This article discusses an innovative organizational approach to reducing medication errors by looking at the human components that contribute to medication errors. The HALT acronym stands for H-Hungry, A-Angry, L-Lonely/ Late, and T-Tired. The article references basic human factors that can create an emotional reaction either prior to, or during medication management that is not normally perceived as significant and contributing to medication errors. As described in the article, HALT was useful in increasing the awareness of nurses to the risk that their feelings create in terms of clinical incidents. This model can also be utilized with other team-building strategies. The process and use of this type of best practice offers an opportunity to "check-in" and see if staff are doing okay, or needed to "HALT". Nurses can utilize the HALT model and help educate other staff about the impact their emotions/ status have on potential safety issues with patients. Additionally, this model will raise self-awareness for those who are at risk and team awareness of employees who may be experiencing problems, which will open up discussion of potential team methods to address the HALT criterion. Encouragingly the HALT model project received positive responses as nursing teams reported that were able to recognize occasions when staff were feeling more stressed, and it allowed a more targeted individual response that also supported the team.
Santos, LL., Camerini, FG., Fassarealla, CS., Almeida, LF., Setta, DXB., Radighieri, AR. (2020). Medication time out as a strategy for patient safety: reducing medication errors. Rev Bras Effern, 74 (1) 1-7.
This journal article discusses medication time-out as a strategy to reduce medication errors. This study was conducted in a small critical care environment and concluded the implementation of the medication time-out strategy contributed to the interception of a high number of medication errors utilizing very few human and material resources. As noted, several other checking back strategies are currently being utilized for higher-risk patients such as surgical safety checklists. This study utilized the medication time-out strategy for checking prescriptions, while in the prescription stage, aiming to avoid the medication error before it occurs. The time-out method was put into practice by reading the particular information from the drug prescription aloud during multi-level rounding so that all team members could catch any potential prescription errors. If prescriptions were changed, additional information was collected and analyzed for a more in-depth study to determine the root cause and decide on further study. The nursing profession directly impacts quality and safety in the use of medications, and utilizing a medication time-out as a tool helps decrease the risk of medication errors as well as promotes an environment of safety. Further research should be done, according to this article, as this technique has a lot of potential for use, was deemed beneficial, needed minimal resources to implement, and significantly reduced medication errors.
Lin, J., Lee, T., Mills, M. (2018). Evaluation of a Barcode Medication Administration Information System. Wolters Kluwer Health, Inc. 36 (12) 596-602.
This article describes the usage of barcode medication administration system usage and its implementation to reduce medication errors. The barcode technology in medication administration can verify specific patient identifiers and the name and appearance of medications. Potential impediments like prescribing and provider handwriting errors are reduced by this technology as well as decreases in errors made when transcribing the specific medication prescription. Barcode medication administration systems provide system-generated alert messages, to remind nursing staff not to overlook processes like double-checks on high-risk medications or verifying patient demographic information. Nurses also commented on how easily the barcode technology system provided an accurate record of medication administration time, as well as provided the latest drug/medication information to share with the patient or families. This technology has proved vital for nursing during medication administration and proved to be highly effective in reducing medication errors.
Environmental Safety and Quality Risks
Nicholson, E.C., Damons, A. (2022). Linking the processes of medication administration to medication errors in the elderly. Health SA Gesondheid, 27 (0), 1-8.
This article discusses the challenges of conducting medication rounds in long-term facility environments. Oftentimes, older patients have complex chronic diseases which require multiple medications to help manage. This increases the length of the medication pass and possible errors during the medication administration phase. Estimating that one older person may take from two to as many as nine different medications per day. Barriers can also include, interruptions during the medication round, creating lengthy medication administrations between 2-4 hours long. This resource discusses the importance of having specific medication policies for guidance and responsibilities beyond the specific scope of practice as well as prechecks that are mandated for specific prescribed medications. Mandatory training, as well as risk management initiatives around medication errors, are encouraged and can help provide valuable insight. This article is appropriate when discussing barriers, and workflow process improvements.
Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Le, L., Sabatier, B. (2021). Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. BMC Nursing 20 (153), 1-11. https://doi.org/10:1186/s12912-021-00671-7
This resource discusses the use of the 'do not interrupt' vest and tests its effectiveness in reducing medication errors during medication administration. Error-provoking conditions include a high workload, or the number of patients being cared for by one nurse, experience or inexperience of the nurse as well as patient factors such as poly-pharmacy. Working environment interruptions and distractions become barriers as well. The ' Do not interrupt" vest was implemented as a tool and worn during the administrative medication round to evaluate the impact. Increased resources needed to be allocated to provide education to patients and families with regard to why the nurses wore the vest and to please not interrupt. The study found that the vest had little or no impact on decreasing medication errors and that interruptions and errors occurred regardless. The article would be useful when discussing environmental safety issues and possible innovative opportunities to affect change. |
Strube-Lahmann, S., Muller-Werdan, U., Klingelhofer-Noe, J., Suhr, R.,, Lahmann, N. (2022). Patient Safety in home care: A multicenter cross-sectional study about medication errors and medication management of nurses. Pharmacol Res Perspect, 10 (e00953) 1-7.
The study reviewed in this article revolves around the home environment and how often medication errors occur. The nurse's education and training, as well as quality control procedures like double-checking medications (DCP) or other common medication processes, were all taken into account. Barriers such as polypharmacy and insufficient exchange or communication of information between homecare staff and providers lead to errors. Reducing pharmaceutical errors requires a culture of positivity that promotes "learning from mistakes" and is a continual effort. This article supports the use of failure mode and effects analysis which utilizes the team approach to finding suitable preventative measures for avoiding future errors in the home environment. According to the study, regular medication training is essential for ensuring the safety of the medication procedure in the homecare setting.
Individual strategies to improve personal and team safety
Athanasakis, Efstratios, RN, (2021). Medication Safety Practices in Clinical Nursing: Nurses’ Characteristics, Skills, Competencies, Clinical Process, and Environment. International Journal of Caring Sciences, 13 (3), 2019-2028.
The significance of registered nurses for patient safety is discussed in this article, particularly with regard to drug administration. It states that nurses most often participate in the last stages of the medication process from preparation, administration, and follow-up response. This resource supports the involvement from the nursing perspective in collaborative reflections with regard to medication safety. It also supports ongoing evidenced-based medication education engagements for staff to help improve medication knowledge and relevant processes or procedures for administration. Areas of time management, self-awareness, and developing mindful strategies during medication administration are explored. Lastly, the journal encourages nurses to understand the complex clinical conditions of their patients and assess the specific situation prior to the administration process.
Hanson, A., Haddad, L., (2023). Nursing Rights of Medication Administration. StatPearls Publishing, (1) Jan. 1-6.
This report discusses the 5 traditional rights of medication administration, Right patient, Right drug, Right route, Right time, and Right dose. The conventional framework is still the main, accepted method for lowering pharmaceutical mistakes. The article also challenges the lack of consideration of including the patient and perhaps adding other rights. Barriers such as nursing workload, and interruptions often make it difficult to comply with all the rights, each and every time. Prevention of medication errors should always include the input of the nurse. Their critical thinking skills as well as their advocating for patient-centered care. Providing medication education and patient involvement creates trust and respect. This is a great article to support the clinical significance of the traditional five rights of medication administration as well as encourage a broader examination of how medication prevention should occur at a system level and should include multiple disciplines.
Jeong, H.-J., & Park, E.-Y. (2022). Patient-Nurse Partnerships to Prevent Medication Errors: A Concept Development Using the Hybrid Method. International Journal of Environmental Research and Public Health, 19(9), 5378. MDPI AG. ttp://dx.doi.org/10.3390/ijerph19095378
This article reinforces patient-centered care and advocates patient participation in preventing medication errors. Communication with the patient and/or families regarding their specific medications increases safety awareness. It also creates an atmosphere of trust and mutual responsibility. Nurses should encourage patients to recognize their specific medications and provide information about allergies. If patients have questions or concerns, they should be addressed prior to administering the medication. A practice of sharing the medication process at the patient level helps with understanding that questions about medication compliance do not always reflect negativity at the healthcare level. The article is a useful resource for nurses who focus on patient-centered care and its use in patient safety with medication errors.
Best Practice for reporting and improving environmental safety issues.
Afaya, A., Konlan, K., Do, H., (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research, 21(1156), 1-10 https://doi.org/10.1186/s12913-021-07187-5
This research article identifies barriers to reporting medication errors and discusses methods for improving this practice. The fact that the nurse is the final safety check in the drug delivery process suggests that it is imperative for nurses to report problems. Nurses report that individual barriers include fear of retaliation or blaming the individual versus the system and worry that medication errors suggest incompetence of the profession. Establishing a specific system for reporting errors is an important measure in improving patient safety. Reporting systems gather vital information that can be analyzed or studied to help prevent further errors. Being able to report events anonymously creates a non-punitive environment and allows for root cause analysis to be conducted at the system level. This article can be utilized to support the need for an error reporting method that allows the user to remain anonymous and encourages analysis of the medication errors, or near-miss safety events to be examined in a non-punitive manner.
Kim, M., Seok, J., Kim, B. (2020). The mediating role of the perceived benefits of using a medication safety system in the relationship between transformational leadership and the medication management climate. Journal of Research in Nursing. 25 (1) 22-34 DOI: 10.1177/1744987118824321
The journal article reports on the importance of an error management climate, and the increased willingness to report errors, which is essential for patient safety. Error management is described as a tactic used to address the root of the error and manage its effects in order to stop it from happening again. Transformational leaders tend to have a management style that encourages a climate of safety at an organizational level and may trend toward using technology-based innovations to help enhance error management. Often integrating e-health technologies and reporting systems into a clinical setting. E-health technology can provide information at the core level and increases the opportunity for reporting. Multiple platforms such as scanning barcode medication systems, smart intravenous pumps, and electronic access to pharmacy information within the electronic medical record. This allows medication review that may be relevant during the administration phase. The article will be useful in supporting both the use of an error management climate and the transformational leadership style.
Mutair, A.A.; Alhumaid, S.; Shamsan, A.; Zaidi, A.R.Z.; Mohaini, M.A.; Al Mutairi, A.; Rabaan, A.A.; Awad, M.; Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines , 8, (46) 1-12. https:// doi.org/10.3390/medicines8090046
This article supports the use of error reporting systems within healthcare settings as a way of preventing medication errors. It discusses the importance of leaders investing in reporting systems that help with identifying where the error occurs while promoting a culture of safety. The reporting system needs to be non-punitive in nature and allows for an investigation of the incident. The research encourages engaging stakeholders so that effective change can be made at the system level. Each medication error should be reviewed as well as processes leading up to the event. Lastly, this resource, clarifies that error reporting systems must be evaluated based on data it produces that can help effect change and prevents patient harm. This journal item will be a good resource when evaluating specific error reporting systems and what areas are important to consider.
References
Afaya, A., Konlan, K., Do, H., (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research, 21(1156), 1-10 https://doi.org/10.1186/s12913-021-07187-5
Athanasakis, Efstratios, RN, (2021). Medication Safety Practices in Clinical Nursing: Nurses’ Characteristics, Skills, Competencies, Clinical Process, and Environment. International Journal of Caring Sciences, 13 (3), 2019-2028.
Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Le, L., Sabatier, B. (2021). Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. BMC Nursing 20 (153), 1-11.
Hanson, A., Haddad, L., (2023). Nursing Rights of Medication Administration. StatPearls Publishing, (1) Jan. 1-6.
Jeong, H.-J., & Park, E.-Y. (2022). Patient-Nurse Partnerships to Prevent Medication Errors: A Concept Development Using the Hybrid Method. International Journal of Environmental Research and Public Health, 19(9), 5378. MDPI AG. ttp:/
Kim, M., Seok, J., Kim, B. (2020). The mediating role of the perceived benefits of using a medication safety system in the relationship between transformational leadership and the medication management climate. Journal of Research in Nursing. 25 (1) 22-34 DOI: 10.1177/1744987118824321
Lin, J., Lee, T., Mills, M. (2018). Evaluation of a Barcode Medication Administration Information System. Wolters Kluwer Health, Inc. 36 (12) 596-602.
Mutair, A.A.; Alhumaid, S.; Shamsan, A.; Zaidi, A.R.Z.; Mohaini, M.A.; Al Mutairi, A.; Rabaan, A.A.; Awad, M.; Al- Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines , 8, (46) 1-12. https:// doi.org/10.3390/medicines8090046
Nicholson, E.C., Damons, A. (2022). Linking the processes of medication administration to medication errors in the elderly. Health SA Gesondheid, 27 (0), 1-8.
Ragau, S., Hitchcock, R., Craft, J., Christensen, M. (2018). Using the HALT model in an exploratory quality improvement initiative to reduce medication errors. British Journal of Nursing. 27 (22). 1330-1135.
Santos, LL., Camerini, FG., Fassarealla, CS., Almeida, LF., Setta, DXB., Radighieri, AR. (2020). Medication time out as a strategy for patient safety: reducing medication errors. Rev Bras Effern, 74 (1) 1-7.
Strube-Lahmann, S., Muller-Werdan, U., Klingelhofer-Noe, J., Suhr, R.,, Lahmann, N. (2022). Patient Safety in home care: A multicenter cross-sectional study about medication errors and medication management of nurses. Pharmacol Res Perspect, 10 (e00953) 1-7.