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Once testing and education are performed a date for the go-live period will be finalized.

Multiple departments will be included in the implementation process including the informatics department, pharmacy, leadership, and representatives from the EHR.

The implementation team will be focused on end-user acceptance, system performance, ongoing maintenance, and the support plan.

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Medication errors: Cut your risk with these tips

Medication errors are preventable. Your best defense is asking questions and being informed about the medications you take.
By Mayo Clinic Staff
Medication errors refer to mistakes in prescribing, dispensing and giving medications. They injure hundreds of thousands of people every year in the United States. Yet most medication errors can be prevented. How can you protect yourself and your family?

One of the best ways to reduce your risk of a medication error is to take an active role in your own health care. Learn about the medications you take - including possible side effects. Never hesitate to ask questions or share concerns with your doctor, pharmacist and other health care providers.

What exactly are medication errors?

Medication errors are preventable events due to the inappropriate use of medications. Medication errors that cause harm are called preventable adverse drug events. If a medication error occurred, but didn't hurt anyone, it's called a potential adverse drug event.

An example of a medication error is taking an over-the-counter product that contains acetaminophen (Tylenol, others) when you're already taking a prescription pain medicine that contains this exact ingredient. This mistake could cause you to take more than the recommended dose of acetaminophen, putting yourself at risk of liver damage.

Another example of a possible medication error is taking a depression medication called fluoxetine (Prozac, Sarafem) with a migraine drug called sumatriptan (Imitrex). Both medicines affect levels of a brain chemical called serotonin. Taking them together may lead to a potentially life-threatening condition called serotonin syndrome. Symptoms of the dangerous drug interaction include confusion, agitation, rapid heartbeat and increased body temperature, among others.

How do medication errors happen?

Medication errors can happen to anyone in any place, including your own home and at the doctor's office, hospital, pharmacy and senior living facility. Kids are especially at high risk for medication errors because they typically need different drug doses than adults.

Knowing what you're up against can help you play it safe. The most common causes of medication errors are:

Poor communication between your doctors

Poor communication between you and your doctors

Drug names that sound alike and medications that look alike

Medical abbreviations

Know how to prevent medication errors

Knowledge is your best defense. If you don't understand something your doctor says, ask for an explanation. Whenever you start a new medication, make sure you know the answers to these questions:

What is the brand or generic name of the medication?

What is the medication supposed to do? How long will it be until I see results?

What is the dose? How long should I take it?

What should I do if I miss a dose?

What should I do if I accidentally take more than the recommended dose?

Are there any foods, drinks, other medications or activities I should avoid while taking this medicine?

What are the possible side effects? What should I do if they occur?

Will this new medication interfere with my other medication(s)? If so, how?

Your doctor can help prevent medication errors by using a computer to enter and print (or digitally send) any prescription details, instead of hand writing one.

Participate in medication reconciliation

Asking questions is essential, but it isn't enough. Your health care providers can follow a process called medication reconciliation to significantly decrease your risk of medication errors.

Medication reconciliation is a safety strategy that involves comparing the list of medications your health care provider currently has with the list of medications you are currently taking. This process is done to avoid medication errors such as:

Missing medications (omissions)

Duplicate medications

Dosing errors

Drug interactions

Medication reconciliation should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting (such as being admitted or discharged from the hospital), health care provider or level of care.

Sharing your most up-to-date information with your health care providers gives the clearest picture of your condition and helps avoid medication mistakes.

Here's what you need to tell your health care providers:

The name and strength of all medications you're taking and when you take them, including prescription medications, herbs, vitamins, nutritional supplements, over-the-counter drugs, vaccines and anything received intravenously, including diagnostic and contrast agents, radioactive medications, feeding tube supplements and blood products

Any medications that you're allergic to or that have caused problems for you in the past

Whether you have any chronic or serious health problems

If you might be pregnant or you're trying to become pregnant

Avoid these mistakes

The following medication errors have happened to some people. Don't make these same mistakes:

Confusing eardrops and eyedrops. Always double-check the label. If a medication says "otic," it's for the ears. If it says "ophthalmic," it's for the eyes.

Chewing nonchewables. Don't assume chewing a pill is as good as swallowing it. Some medications should never be chewed, cut or crushed. Doing so may change how they're absorbed by the body.

Cutting up pills. Never split pills unless your doctor or pharmacist has told you it's safe to do so. Some medications shouldn't be cut because they're specially coated to be long acting or to protect the stomach.

Using the wrong spoon. The spoons in your silverware drawer aren't measuring spoons. To get an accurate dose, use an oral syringe (available at pharmacies) or the dose cup that came with the medication.

Make safety a habit

Get into the habit of playing it safe with these medication tips:

Keep an up-to-date list of all your medications, including nonprescription drugs and supplements.

Store medications in their original labeled containers.

Keep your medications organized by using a pillbox or an automatic pill dispenser.

Save the information sheets that come with your medications.

Use the same pharmacy, if possible, for all of your prescriptions.

When you pick up a prescription, check that it's the one your doctor ordered.

Don't give your prescription medication to someone else and don't take someone else's.

A final word on medication errors

"Don't ask, don't tell" is never a smart policy when it comes to medications and your health. Don't hesitate to ask questions or to tell your health care providers if anything seems amiss. Remember, you're the final line of defense against medication errors.

If despite your efforts you have problems with a medication, talk with your doctor or pharmacist about whether to report it to MedWatch - the Food and Drug Administration safety and adverse event reporting program. Reporting to MedWatch is easy, confidential and secure - and it can help save others from being harmed by medication errors.

Show references

See more In-depth

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Medication errors are preventable. Your best defense is asking questions and being informed about the medications you take. By Mayo Clinic Staff Medication errors refer to mistakes in prescribing, dispensing and giving medications. They injure hundreds of thousands of people every year in the United States. Yet most medication errors can be prevented.

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Nurses' Satisfaction with Med Administration after Introduction of EHR

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Nurses' Satisfaction with Med Administration after Introduction of EHR

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After testing has occurred, the informatics team will ask for at least two RN volunteers to become superusers to aid the staff once the changes have occurred.

A command center will be established made up of both IT technicians and informaticists.

The command center will make sure project specific support is available 24/7 for technical support for the first month following go-live.

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1. Evaluate the current medication administration workflow within the NICU at North Jersey Health System.
2. Describe all steps that are taken when administering a medication. 3. Identify common workflow interruptions, barriers, and workarounds within the medication administration process. This will be done by anonymous

questionnaires to the end-users.
4. Identify improvement opportunities and develop a plan to implement changes.
5. Provide training and education to affected staff members.
6. Contact the informatics team to discuss and implement changes within the EHR.
7. Evaluate the implemented changes.
8. Provide support to affected staff with the use of super-users and a support phone number that can be always accessed.

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Although more computers were available with the addition of the WOW, the batteries needed to be charged every shift. A future suggestion is to have extra WOWs and battery packs.

The wireless scanners were reliable but had connectivity issues. If the end-user clicked a button too many times or walked too far from the WOW, the wireless scanner would disconnect. A solution was quickly formulated to remedy this issue by securing laminated, step-by-step instructions to each WOW of how to resynchronize the scanner to the chosen computer.

The integrity of the post-implementation surveys was questioned. Due to the immaturity of the research project staff were concerned there would be consequences of reporting workarounds. In the future an observed component of data collection relating to workarounds would be added.

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The new workflow will first be tested in a test environment using a testing production of the current EHR.

Test patients and three of the most commonly given medications will be added to this environment.

Management and 2-3 volunteer staff nurses will test  these changes by completing a medication administration in the testing environment.

Testing will conclude with the subjects completing a questionnaire answering what part of the intended changes they found useful and what still needs to be changed.

If any changes are made re-testing must occur.

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The metrics previously identified should be tracked and monitored over the next six months to ensure there were no new barriers or interruptions in workflow created by these modifications or changes in practice.

The long-term goal of this single unit roll out would be to implement these changes with custom adjustments to the entire hospital in the future.

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1. What is a common workaround you see at your place of employment? Are there any steps being taken to eliminate these workarounds?
2. What is an example of a patient safety issue you have witnessed or heard of created by a workaround?

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This project aims to create a more streamlined workflow during medication administration in the NICU which will decrease the instance of nurse workarounds thus increasing patient safety.

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Appraise the percentage of accurately scanned medications in the NICU at NJHS and increase this percentage to 80%

Investigate instances of medication administration issues resulting in patient harm and decrease this percentage to 0%.

Analyze the cause of self-reported workarounds by the end-user and work to eliminate these causes.

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FINAL NUR 585 Workflow Redesign Assignment BROWN&DUBIEL

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Patient Safety Through Bar Code Scanning

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1. End-user enters patient chart and accesses the Medication Administration Record (MAR).

2. End-user must highlight and double-click the medication that is being administered.

3. End-user will now be prompted to scan the patient’s identification bracelet. This must be repeated to continue.

4. Once the patient is scanned, the end-user is prompted to hit the ‘Enter’ key. The MAR simply states, ‘Hit Enter Now’. No other information is available on this screen.

5. The MAR prompts the end-user to check if the conditions are met to proceed with medication delivery. This screen will show regardless of if there are actual parameters for medication administration. The nurse must choose either ‘Yes’ to continue or ‘No’ to exit.

6. The nurse is again prompted to hit ‘Enter’ on an otherwise blank screen.

7. The end-user is now prompted to scan the medication.

8. The end-user will now be prompted to choose to either ‘Administer Now’ or ‘Exit’.

9. The end-user is prompted to ‘Accept’.

10. The medication is now successfully scanned and is ready for administration.

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1. Access patient record.

2. Review allergies with patient, select ‘Mark as reviewed’.

3. Open MAR.

4. Scan patient’s identification band and verify patients full-name and DOB.

5. Scan medication that is due.

6. Verify drug name, correct dose, correct route, and correct time.

7. Select ‘Administer now’.

8. The medication is now scanned and ready to be administered to the patient.

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A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer," according to the National Coordinating Council for Medication Error Reporting and Prevention.

Medication errors can occur throughout the medication-use system. Such as, when prescribing a drug, upon entering information into a computer system, when the drug is being prepared or dispensed, or when the drug is given to or taken by a patient.

The U.S. Food and Drug Administration (FDA) receives more than 100,000 U.S. reports each year associated with a suspected medication error. FDA reviews the reports and classifies them to determine the cause and type of error. The reports come from drug manufacturers, and healthcare professionals and consumers through MedWatch, the Agency's safety information and adverse event reporting program. Serious harmful results of a medication error may include:

Death

Life threatening situation

Hospitalization

Disability

Birth defect.

Looking for ways to reduce medication errors

FDA looks for ways to prevent medication errors. Before drugs are approved for marketing, FDA reviews the drug name, labeling, packaging, and product design to identify and revise information that may contribute to medication errors. For example, FDA reviews:

Proposed proprietary (brand) names to minimize confusion among drug names. With the help of simulated prescriptions and computerized models, FDA determines the acceptability of proposed proprietary names to minimize medication errors associated with product name confusion.

Container labels to help healthcare providers and consumers select the right drug product. If a drug is made in multiple strengths - e.g., 5 mg, 10 mg, and 25 mg, - the labels of those three containers should be easy to differentiate. The label design may use different colors or identify the strength in large bold numbers and letters.

Prescribing and patient information to ensure the directions for prescribing, preparing, and use are clear and easy to read.

After drugs are approved for marketing in the United States, FDA monitors and evaluates medication error reports. FDA may require a manufacturer to revise the labels, labeling, packaging, product design or proprietary name to prevent medication errors. FDA may also issue communications alerting the public about a medication error safety issue, by way of Drug Safety Communications, Drug Safety Alerts, Medication Guides and Drug Safety Podcasts.

FDA collaborates with external stakeholders, regulators, patient safety organizations such as the Institute for Safe Medication Practices (ISMP), standard-setting organizations such as the U.S. Pharmacopeia, and researchers to understand the causes of medication errors, the effectiveness of interventions to prevent them, and to address broader safety issues that may contribute to medication errors.

Getting the right drug to the right patient

FDA also put into place rules requiring barcodes on certain drug and biological product labels. Barcodes allow healthcare professionals to use barcode scanning equipment to verify that the right drug -- in the right dose and right route of administration -- is being given to the right patient at the right time. This system is intended to help reduce the number of medication errors that occur in hospitals and other healthcare settings.

FDA has published several guidances to help manufacturers design their drug labels, labeling, packaging, and select drug names in a way to minimize or eliminate hazards that can contribute to medication errors. For example, in 2016, FDA issued a final guidance titled,Safety Considerations for Product Design to Minimize Medication Errors. To avoid errors and encourage safe use of drugs, the guidance recommendations include:

Tablets and other oral dosage forms should have distinct and legible imprint codes so healthcare providers and consumers can verify the drug product and strength.

Oral syringes and other dosing devices co-packaged with a liquid oral dosage form should be appropriate for the doses to be measured. Dosing errors have been reported when an oral syringe is labeled in milligrams but the dose is prescribed in milliliters.

The package design should protect the consumer against incorrect use. Medications applied to the skin (topical) should not be packaged in containers that look like the containers usually associated with eye, ear, nasal, or oral products. Similar looking containers have resulted in people putting a topical product in the eye, ear, nose, and mouth.

Over-the-counter and prescription drug labeling

According to a Harris Interactive Market Research Poll conducted for the National Council on Patient Information and Education and released in January 2002, consumers tend to overlook important label information on over-the-counter (OTC) drugs. In response to that report, FDA now requires a standardized "Drug Facts" label on more than 100,000 OTC drug products. Modeled after the Nutrition Facts label on foods, Drug Facts helps consumers compare and select OTC medicines, and follow instructions. The label clearly lists active ingredients, inactive ingredients, uses, warnings, dosage, directions, and other information, such as how to store the medicine.

In 2006, FDA revised its rules for the content and format of prescribing information for prescription drug and biological products. The new look helps healthcare professionals find the information they need more easily and quickly. FDA also makes updated prescribing information available on the Web at Drugs@FDA.

Consumers play an important role

Consumers can also play an important role in reducing medication errors. Here are some drug safety tips:

Know the various risks and causes for medication errors. See ISMP's consumer web page, ConsumerMedSafety.org, for helpful tools and resources to protect yourself from medication errors.

Find out what drug you're taking and what it is for. Rather than simply letting the doctor write you a prescription and send you on your way, be sure to ask the name of the drug and the purpose of the drug.

Find out how to take the drug and make sure you understand the directions. Ask if the medicine needs to be kept in the refrigerator.

Check the container's label every time you take a drug. This is especially important if you are taking several drugs because it will lower your risk of accidentally taking the wrong medicine.

Keep drugs stored in their original containers. Many pills look alike, so keeping them in their original containers will help know the name of the drug and how to take them. If you are having trouble keeping multiple medications straight, ask your doctor or pharmacist about helpful aids.

Keep an updated list of all medications taken for health reasons, including OTC drugs, supplements, medicinal herbs, and other substances. Give a copy of this list to your healthcare provider.

Be aware of the risk of drug/drug or drug/food interactions.

If in doubt or you have questions about your medication, ask your pharmacist or other healthcare provider.

Report suspected medication errors to MedWatch.

For More Information

Food and Drug Administration
Think it Through: A Guide to Managing the Benefits and Risks of Medicines

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A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer," according to the National Coordinating Council for Medication Error Reporting and Prevention.

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Systematic Review of HIT on Nurses' Time

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Systematic Review of HIT on Nurses' Time

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Pharmacy: Pharmacists and Pharmacy Technicians

NICU Leadership

Quality Improvement

Risk Management

IS/Informatics Department

NICU Registered Nurses

Engineering

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Medication errors create an opportunity for financial burden on a healthcare institution both immediately and over time.

These costs include the medication, procedures, and treatments needed to address the potential adverse reactions in patients and prolonged hospitalizations resulting from these errors.

The financial burden of improper medication administration and poor documentation can directly impact budgets and reimbursement resulting in financial loss.

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Internal customers include nurses and physicians within the network.

External customers include patients and the surrounding community.

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Start date - July 8, 2021.
The LEAN project charter will be approved by July 15, 2021.
The current state workflow will be completed by July 25, 2021.
The future state workflow will be developed by July 26, 2021.

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Simulation in a training environment will be utilized.

The first half of the class will be didactic and cover every facet of the intended changes.

The second half of the class will include a simulation experience and focus on practicing the new medication administration process on the new WOWs with attached wireless scanners.