Medication Error Prevention by Sarah Lohnes https://padlet.com/slohnes/3p96u6sdisioe2a3 in an Acute Healthcare Setting | NUR 416 en-us 2022-04-11 17:55:13 UTC 2022-04-18 21:47:41 UTC hello@padlet.com INTRODUCTION: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139866899 2022-04-11 21:45:27 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139866899 CONCLUSION: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139867683 2022-04-11 21:45:57 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139867683 What is an Automated Dispensing Cabinet or System (ADC) or (ADS)? slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139906133 "Hospitals have implemented automated dispensing systems and bar code technology to decrease errors and keep an accurate inventory of drugs on the unit. Automated dispensing systems have helped reduce dispensing errors by 31% through packaging and bar coding of medications" (Godshall & Riehl, 2018, Para. 6).]]> 2022-04-11 22:37:48 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139906133 ISSUE: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139907878 What is the problem?
On a medical-surgical unit, does having a single patient dispensing process versus an unlimited dispensing process decrease medication errors? Godshall & Riehl, (2018) state "Medication errors can be lethal, and it is estimated that up to 7,000 patients a year die from these preventable mistakes, which cost the healthcare industry up to $30 billion a year" (para. 1).

Who does it affect?
"In fact, it's estimated that a hospitalized patient is subject to at least one medication error per day with variation across facilities" (Godshall & Riehl, 2018, Para. 1). It affects the patients who are harmed and the healthcare professional who caused unintentional harm to patients, which leaves an everlasting impact on that person's mental health.

How?
"Adverse drug events, defined as harm experienced by a patient because of exposure to a medication, affect nearly 5% of hospitalized patients" (Godshall & Riehl, 2018, Para. 1).

Where?
U.S. hospitals or any acute healthcare setting with an ADC to pull medications from to administer to patients. 

When?
Rogers et al., (2017) state "Nurses spend 16–27% of their time on medication administration tasks that together serve as one of the final checks in the process of preventing medication errors" (p. 2066). To help minimize the likelihood of these preventable mistakes, nurses are taught the "Six Rights of Medication Administration," which include the right patient, right medication, right time, right route, right dose, and right documentation.

Why?
"One survey of RNs noted that personal neglect, heavy workload, and staff turnover can be major factors influencing the recurrence of medication errors. The survey's authors identified three elements: identification, interruption, and correction" (Godshall & Riehl, 2018, Para. 8).
]]> 2022-04-11 22:39:53 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139907878 RECOMMENDATIONS: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139913474 1. Start implementing the automated dispensing cabinet/system (ADC/ADS) to force the nurses to have a timeout in between pulling medications for patients. Perhaps a 10-minute window in between being allowed to pull medications from the ADCs, unless it is an emergency override for a patient. This would allow the nurse more time with the patient to complete a quick head-to-toe assessment while in the room and chart in real-time. Ensure prior to this during bedside report you looked around notating at materials needed for medication administration. 

2. Assigning a unit nurse at the hospital to audit patient charts for nurses who pull medications too close together or override the system continuously in order to pull medications for all their patients at once. This would hold the nurses accountable for their actions and reprimand them for continued disobedient behavior. 

3. Only allow a maximum of two nurses in the medication room at a time by locking the door after two ID badge swipes to alleviate multiple interruptions that nurses encounter in the medication room. This feature already exists on the medication doors when standing too close to the door. ]]> 2022-04-11 22:46:57 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139913474 LITERATURE: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139916950 Investigating inpatient medication administration using the theory of planned behavior:
  • Out of 755 nurses, only 271 (34%) submitted usable responses.
    • A favorable attitude toward safe ADC dispensing practices and a supportive subjective norm was strongly associated with the intent to use ADCs properly.
    • Work experience years, demographics, and patient workload all had contributing factors in influencing the safe use of ADC, which indicates that peer influence at the unit level could have a positive effect. 
    • (Rogers et al., 2017)

Impact of automated dispensing cabinets on dispensing errors, interruptions, and pillbox preparation time:

  • A high dispensing-error rate was observed among wards using Traditional Ward Stock methods. 
  • Using ADCs connected to computerized physician order entry and installed in a dedicated room, Wards had fewer dispensing errors and interruptions, and their nurses prepared pillboxes faster.
  • Wards participating in a 'More Time for Patients' Project - Lean Management project had lower error rates than wards not using this approach.
  • (Jumeau et al., 2021)

Preventing medication errors in the information age:
  • The survey's authors identified three elements: identification, interruption, and correction.
    • Identification is the 6 Rights of Medication Administration.
    • The frequency of interruptions during medication administration increased the risk of medication errors and severity.
    • Correction means clarifying medication alerts or warning with a pharmacist or provider without bypassing it and placing the patient in harm's way.
  • (Godshall & Riehl, 2018)
]]> 2022-04-11 22:51:40 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139916950 slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139917951 2022-04-11 22:53:13 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139917951 ANAYLSIS: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139921259 Nurse's Current Roles
Having a standardized process that includes removing only one patient’s medication during each ADC “pull” and then directly administering the medication to the patient can reduce the possibility of administration errors" (Rogers et al., 2017). Rogers et al, (2017) state "However, removal and administration of medications from ADCs “one patient at a time” is often not done; a multicenter study demonstrated that the majority of nurses simultaneously prepared and administered medications for multiple patients during a single ADC pull during an average shift. Potential reasons for this unsafe practice include provider workload, perceived lack of ease, lack of policy enforcement by institutional leadership, and interruptions during nursing shifts" (p. 2066). Currently, at Sentara, the majority of nurses pull most of their medications at once. Being a Magnet hospital I found this surprising that there was no chart auditing system in place for medication pull times either to hold the nurses accountable. ]]> 2022-04-11 22:57:53 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139921259 ANAYSIS: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139922357 Importance of Nurse's Involvement
Implementing the single patient medication dispensing system would allow for less confusion when it comes to medication administration and only having one patient's medications on the nurse. Nurse's already utilize time management skills from the start of their day surrounding medication administration times for their patients, so this would just give more patients face time with the nurses. Again, ensuring you have everything needed for medication administration while you're in there for the morning bedside report is crucial to saving time by bringing supplies with you. ]]> 2022-04-11 22:59:23 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139922357 ANAYLSIS: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139923625 Challenges or Barriers
The challenges or barriers to nursing involvement in getting the single patient medication dispensing system implemented at Sentara would be getting involved with the leadership management team that would have to approve it. After approval, it would take financing to get the IT department involved in actually implementing into each ADC. ]]> 2022-04-11 23:01:05 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139923625 slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139927500 2022-04-11 23:06:21 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2139927500 Nursing Responsibilities of Med Administration: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2145762606 2022-04-17 01:40:08 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2145762606 REFERENCES: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2145823042 2022-04-17 04:43:03 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2145823042 REFLECTIONS: slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2146270144 Sentara College of Health Sciences has helped prepare me to take on a leadership role once I transition into my professional nursing practice because they have first equipped me with the knowledge of a bachelorettes degree which has helped steer my nursing decision making in the best way possible and second they have helped mold me into the change agent that I have become today. If it's unsafe, I'm calling it out. If it can be done more effectively, I'm calling it out. Why be a stagnant floor nurse? Once I hit my hours, I'm furthering my education with the Progressive Critical Care Nursing certificate. ]]> 2022-04-17 22:50:07 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2146270144 slohnes https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2146584232 2022-04-18 04:50:07 UTC https://padlet.com/slohnes/3p96u6sdisioe2a3/wish/2146584232