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Chang Proposal - Milestone #4

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NR 451- Capstone Project Milestone #4: Design for Change Proposal

Christopher D'Ambrose

NR 451 Capstone Course

Quality of patient care is a paramount concern of healthcare professionals. When nurses experience interruptions while they are working, the quality of care patients receive can be negatively impacted. Interruptions have been shown to disrupt working memory, disrupt on-duty focus, induce frustration and stress, contribute to accidents, and lead to patient care errors (Bennet, et al., 2010). Interruptions that occur when nurses administer medication to patients are a particular concern. The incidence of interruptions is higher than might be surmised; according to Day (2010), 19.8% of all procedures did not have any disruptions or clinical errors. Biron, et al. (2009) reviewed 14 observational studies of nurses providing patient care, in which they found that 6.7 interruptions occurred each hour during mediation administration. This data indicates that a majority of patient cases involve some type of mistakes from distracting interruptions (Day, 2010).

To address these issues, a new approach needs to be taken by introducing a nursing plan that emphasizes certain standard procedures and practices. The literature has shown that some of these procedures and practices are associated with a decrease in the frequency of interruptions to nurses during the administration of medication (Bennet, et al., 2010; Pape, et al., 2005; Relihan, et al., 2010). The interventions employed in these studies made error reduction salient in practice, made it easier for healthcare professionals to pay closer attention to the tasks of mediation administration, and functioned to reduce the chance of errors occurring.

Pape, et al. (2005) found that the challenge of reducing interruptions during medication administration can be addressed through the use of the following: a medication administrative checklist, no talk signage, interruption vests worn by nurses printed with the phrase "Do Not Disturb." Rathmann, et al. (2007) found that the incidence of interruptions was reduced by 89% by establishing patient quiet zones during medication administration. Moreover, Biron, et al. (2009) found that and informing staff about the non-interruption strategies also helped to reduce errors.

In the tradition of evidence-based nursing, the overall planning process for designing a change in practice or procedures may follow the Rosswurm and Larrabee's (1999) 6-step change plan model. Taken together, the proven strategies from the literature and the systematic framework for building a research utilization program will work to identify the value of the plan in the desired context, and how implementing the plan with fidelity can improve the quality of care patients are receiving (Pape, et al., 2005; Rosswurm & Larrabee, 1999).

Contribution to the Future of Healthcare

The change model developed by Rosswurm and Larrabee introduces nursing staff to the evidence-based nursing practice, evaluates the potential for clinical practice change, and focuses on incorporation of new ideas into the current practices approved by healthcare professionals. The basic idea is to utilize these theories to shift the procedures in addressing specific problems, which could have an impact on quality. The 6-step change plan model is both a theory-driven framework and a pragmatic approach that empowers nurses to solve the problem of interruptions during medication administration through their own independent nursing decisions and actions. The evidence-based change plan proposes to establish use of a standardized checklist to be used during the processes associated with the administration of medicine. The checklist includes implementation of a number of practices that have been shown to effectively reduce the incidence of interruptions during medicine administration. Use of the checklist is anticipated to decrease the chance of errors occurring and establish a new strategy for everyone to follow; the overarching benefit to the future of nursing is a clear path to practice that reduces medication administration errors. The key stakeholders in this proposed evidence-based change of practice include nursing staff, other staff on the floor during the administration of medication, and -- naturally -- the patients receiving medication and care.

Change Model Overview

The Rosswurm and Larrabee (1999) 6-step model is designed to provide a framework of reference for systematically bringing about modification of clinical practice to an evidence-based change. Substantive strengths of the model are the incorporation of change theory and a step-by-step guide to research utilization -- and a thorough grounding of clinical staff in the theoretical foundations and the pragmatic use of standardized nomenclature to communicate about and evaluate the change. The six steps of the model are as follows:

1. Assess the need for change in practice.

2. Link the problem with interventions and outcomes.

3. Synthesize the best evidence.

4. Design a change in practice.

5. Implement and evaluate the practice.

6. Integrate and maintain the practice change.

Step 1: Assess the Need for Change

The practice problem of interest is: Do interruptions zones limit distractions and medical errors? The first step in the evidence-based process is to clarify whether concerns about an aspect of clinical practice are based on an actual problem of sufficient potential impact to warrant taking action. Indeed, robust support exists in the literature for addressing the problem of interruptions and errors during the administration of medication. Without a standard protocol for understanding or implementing safeguards to deal with interruptions during the administration of medication, nurses are unlikely to effect a substantive error reduction. High medication error rates can lead to medical malpractice litigation against individual clinicians and healthcare organizations.

A growing body of research indicates that interruptions are strongly associated with medication administration errors. Biron et al. (2006) found that errors occurred on average of 43.9% of the time when the procedures of medication administration were conducted. In a study of medical and surgical units, (Ferguson, 2005; Hall, 2010) 13,025 interruptions were observed; members of the health team were found to be the primary source of the interruptions. Patient care in medical institutions inevitably occurs in contexts that are characterized by some environmental noises and a fairly continual stream of face-to-face and telephone communication. The incidence of interruptions in the research studies cited does not appear to differ markedly from the rates of disruption experienced by this author in the context of the proposed study. To address these challenges, all stakeholders (nurses, visitors, administrative and custodial personnel, patients, and doctors) must understand the threat to patients, staff, and facility if the practice problem is not addressed with sufficient rigor. Acknowledging the importance of the issue is a first step to ensuring that staff is adequately motivated to embrace clinical practice transformations and improve the quality of care patients are receiving.

Step 2: Link the problem, interventions, and outcomes

Research indicates that the medication administration interruption problem is common to a variety of healthcare organizations (Biron, et al., 2009; Ferguson, 2005; Hall, et al., 2010; Kreckler, et al., 2008; Relihan, et al., 2010). An overarching goal of medication administration error prevention programs is to reduce the level of chaos in the immediate environment and to limit disruption of procedures in which nursing staff are engaged at the time medication is being administered (Relihan, et al., 2010). To inform medication administration error prevention programs, researchers have studied the type and occurrence of nursing tasks that are interrupted, and the source and incidence of interruption. The administration of medication is considered the most frequently occurring nursing task (Biron, et al., 2009; Hedburg & Larson, 2004)). Nursing colleagues have been found to be the primary source of interruption to nursing tasks (Biron, et al., 2009; Hedburg & Larson, 2004), a variable that is associated with disruption associated with the system of medication administration. System failures include missing equipment, missing medication (Hurley et al., 2007), and other difficulties that Tucker and Spear (2006, p. 646) have described as "the inability of the work system to reliably provide information, services, and supplies when, where, and to whom needed." Support exists in the literature to include a component for educating nursing and other staff and informing inpatients in medication administration plans (Relihan, et al., 2010). Moreover, Biron, et al. (2009) asserted that effective preventative programs must work to improve the actual system of mediation administration.

A constellation of intervention strategies has been used with varying degrees of success (Pape, 2003, 2009; Pape, et al., 2005; Relihan, et al., 2010). The most successful medication administration error prevention programs utilize a combination of several distinct strategies designed to increase the reliability of the system, to focus the attention of nursing staff, and to induce patients and others to refrain from behaviors that would disrupt the administration of medication (Pape, 2003, 2009; Pape, et al., 2005; Relihan, 2010).

Educational sessions that expose nursing and other staff to evidence-based interventions that effectively reduce the rate of medication administration errors can serve to motivate staff members to make adjustments to clinical practice. Implementation of the research-based practices is highly likely to result in a decrease in the number of mistakes and contribute to improved patient care quality (Biron, et al., 2009; O'Brien, 2010; Pape, 2003, 2009; Pape, et al., 2005; Relihan, 2010).


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