- Educate staff regarding medication error prevention measures
- Errors occur across the patient care continuum
- Common causes: distortions, distractions, and illegible writing
- Cause many adverse events, including drug errors
- Nurses must understand common risks at facilities
The in-service training will educate entity-based nurses about medication error causes and their mitigation. They are a major concern to staff who prescribe, document, transcribe, dispense, and administer drugs (Da Silva & Krishnamurthy, 2016). Common causes include distortions, distractions, and illegible writing that lead to drug errors. Nurses must understand potential risk factors and their prevention.
- Course objective: enhance medication use safety and error prevention
- Define a sentinel event and medication error
- Explain root-cause analysis and human factors in error events
- Identify strategies for preventing medication errors
- The duration of the course: 2-3 days
The in-service training seeks to improve medication use safety at Clarion Court to prevent error recurrence. The course will take 2-3 days. Nurses will learn to recognize sentinel events and medication errors and perform root-cause analysis to identify associated human factors. More focus will be on evidence-based prevention strategies – electronic medication cards, team communication, and patient identifiers (Gorgich et al., 2016). Delivery will be through lectures, videos, and simulations.
- Improve active listening, teamwork, and mutual respect
- Understand human factors influencing errors
- Identify situations prone to medication errors
- Apply specific measures to prevent errors
- Adhere to patient safety procedures
An expected practice outcome of this course includes improved team communication, teamwork, and respect. Nurses will also understand human factors that cause errors and learn to identify situations that increase the risk. Additionally, they will apply evidence-based strategies to prevent errors and improve patient safety at the facility.
Safety Improvement Plan: Overview
- Current problem: increasing medication error incidents
- Inferior nurse-CNA communication – causes mistrust and misunderstanding
- Nurse fatigue due to work overload
- Plan: team empowerment, technology use, and more staff
- To address miscommunication, fatigue, and distraction
The current problem addressed through the proposed plan entails increasing medication errors at Clarion Court facility, poor communication between nurses and certified nursing assistants (CNAs) that breeds mistrust and misunderstandings, and nurse fatigue due to heavy workloads. Empowering CNAs through skills training will increase their motivation and role competency.
Safety Improvement Plan: Importance
- High error incidents reported for six months
- A serious sentinel event – a near-fatal drug overdose
- More patient safety issues, including missed medication
- Non-adherence to safety procedures by CNAs
- Poor nurse-CNA communication, understaffing and overworking
Clarion Court needs to address medication errors to promote patient safety outcomes and reduce harm. A recent spike in error incidents, including one that almost resulted in patient death due to drug overdose, call for correct responses to address the problem. However, systemic issues, among them CNAs not following safety procedures and understaffing, must be prioritized.
- Active participation of the audience in recognizing risks
- Investigate the causes of medical errors and share findings
- Embrace technology meant to prevent medication errors
- Effectively communicating with other team members
- Avoid distraction and minimize noises in units
Successful implementation of the proposed plan will require the active participation of the staff audience in recognizing, monitoring, and reporting human factors that increase the risk of medication errors. Nurses will also adopt technologies such as clinical communication and collaboration (CC&C) platforms and electronic medication cards to promote collaboration and reduce miscommunication. Using special signs and two-hourly rounding can help minimize noises and promote focus.
- Adherence to the rights of drug administration
- Effective communication among nurses – CC&C and medication cards
- Educating patients and families about medication regimens
- Independent verification of doses by nurses before administration
- Designing work shifts to minimize work overloads
The audience will be critical to the success of the improvement plan as the implementers. They will apply the five rights framework in practice to ensure safe drug administration (Jones & Treiber, 2018). They will use CC&C platforms and design work schedules to reduce workloads. They will also do independent double checks of dosage levels before administration and design work schedules to reduce fatigue-related errors.
- Efficient practice due to well-managed workloads
- Enhanced knowledge about safe prescription and administration
- Better communication (documentation and standardization of orders)
- Conducive physical environment – fewer distractions in the wards
- Reduced liability for medication errors
Nurses will have a voice in work schedules, which will reduce workloads and improve motivation and clinical performance. Enhanced pharmacological knowledge of nurses through training of CNAs will result in safe medication administration. The technologies implemented will enhance communication (standardized orders) and reduce distraction that contributes to sentinel events. Role efficacy will reduce blame or legal liability for medication errors.
New Process and Skills Practice
- Computer systems and tools to lower errors
- Optimal work scheduling and collaboration to reduce fatigue
- Conducive environments that improve attention and focus
- Pharmacological skills – timely administration and drug side effects
- Accurate medication calculation and dosage level
The new and advanced processes and skills will be integrated into the improvement plan. According to Araújo et al. (2019), Computerized Physician Order Entry or Clinical Decision Support System will ensure that orders are standardized to reduce medication errors. Optimal work scheduling and enhanced collaboration through CC&C platforms will enhance efficiency and minimize fatigue. The new nursing skills required include knowledge in pharmacological administration and calculating the correct dosage.
- Online discussions through the NowComment application
- Moderate real-time chat rooms involving the audience
- Participants to ask questions and reply to messages
- Reflect on personal experiences and near-misses
- Suggest appropriate interventions for reducing errors
A live discussion activity will be used to promote interaction among nurses. Through the ‘NowComment’ application, participants can pose questions to each other and receive appropriate responses. The questions they may ask include how to educate patients/families about medication regimens? And, how do we manage fatigue in practice? Online discussions will also enable the audience to reflect and share personal experiences and suggest interventions for reducing the medication error risk.
- Posing timely open-ended questions to the audience
- Individual written responses to post-training survey questions
- Structured formative assessment of individual progress
- Summative assessment at the end of the course
- Reflections on course content and experiences
Diverse methods will be used to solicit feedback from the audience on the improvement plan. Timely open-ended questions during training sessions will elicit responses about the course and medical error prevention actions. Feedback from a post-training survey will indicate the efficacy of the course in attaining the intended outcomes. Structured formative assessments will indicate each individual’s progress while the results of summative evaluations and in-session reflective experiences will show the skills acquired by participants.
- Educational – promote reflection on individual experiences
- Motivate those failing to complete the course successfully
- Appreciating efforts of the staff audience
- Interactive modes, including role-plays and simulations
- Prepare nurses to engage more with medication safety
Feedback from the surveys and assessments will enrich reflective experiences in future courses and motivation of those not meeting the learning outcomes. It will inform the design of interactive modes for more effective learning. The feedback will also help structure content on medication dosage calculation.
Araújo, B. C., Melo, R. C., Bortoli, M. C., Bonfim, J. R., & Toma, T. S. (2019). How to prevent or reduce prescribing errors: An evidence brief for policy. Frontiers in Pharmacology, 10, 439-447. Web.
Da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: A patient case and review of Pennsylvania and National data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 31758. Web.
Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 220. Web.
Jones, J. H. & Treiber, L. A. (2018). Nurses’ rights of medication administration: Including authority with accountability and responsibility. Nursing Forum, 53(3), 299-303. Web.