Developing Delivering and Reassessing an Evidence-Based Program to Decrease Medication Errors Annotated Bibliography

Excerpt from Annotated Bibliography :

DRACH-ZAHAVY A. & PUD D. (2010) Learning mechanisms to limit medication administration errors. Journal of Advanced Nursing 66(4), 794 -- 805.

doi: 10.1111/j.1365-2648.2010.05294.x

In this paper, the learning mechanism used in the limiting of medication errors of studied. The paper is a report of a study the was carried out to identify as well as test the learning mechanism's effectiveness in the context of nursing staff in hospital wards as a way of limiting the errors associated with medication administration.

The background of the paper is the influential report titled 'To Err Is Human' and has a deep emphasis on the role of effective team playing in the reduction of the level of medication errors.

The study involved the random recruitment of 32 hospital wards where data were collected in Israel via a multi-method as well as multisource approach. The medication administration errors were effectively defined as any form of deviation from the policies, procedures as well as best practices in the process of medication administration. They were identified via a semistructured observation of the nurses' medication administration. The organizational learning was then gauged using semi-structured interviews with various head nurses while the previous year's medication administration errors which were reported were effectively assessed by means of administrative data.

The interview data indicate that there are 4 learning mechanisms patterns that were used in an attempt to effectively learn from the medication administration errors. These are integrated, the non-integrated, supervisory as well as patchy learning. A regression analysis indicated that even though the integrated pattern of learning mechanisms had an association with a decrease in the number of errors, the otherwise non-integrated pattern had an association with an increase in the number of errors. The supervisory as well as patchy learning mechanisms never had any associations with the errors.

The conclusion of the study was that superior learning mechanisms are the ones that are a representation of entire team learning.

Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D.Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Adm. 2002 Oct;32(10):509-23.

In this paper Benner at al explored the individual, practice as well as system causes of nursing errors.The paper indicated that the practice errors by various nurses can effectively cause harm to the patients, their families as well as to the nursing profession. They pointed out that the nursing errors that are reported by the U.S. State Boards of Nursing are very serious and therefore analyzing the data has a lot of potential in revealing ways of developing better strategies to be used in the reduction of dangerous errors. The guiding rationale is the identification of the appropriate categories that is ventral to the role of nurses as well as the errors in healthcare.b The study involved the analysis of twenty one cases of nursing arrors sourced from nine State Boards of Nursing files. The analysis was carried out in order to develop taxonomy of the nursing errors. About eight categories of nursing errors that represented a broad range of the possible errors as well as contributive factors were effectively identified. These were lack attentiveness, lack of fiduciary concerns, lack of interventions as well as inappropriate judgment.

Fry MM, Dacey C. (2007)Factors contributing to incidents in medicine administration. Part 1. Br J. Nurs. 2007 May 10-23;16(9):556-8.

In this article, Fry and Dacey (2007) explore the various factors which contribute to various errors in the administration of medicines via a detailed literature review. They pointed out that medication incidents are cause of very serious harm to various patients. The paper indicated that in a typical hospital, about seven thousand medication doses are administered every day (Audit Commission, 2002). The costs of the errors to practitioners, patients as well as the NHS is quite significant. The paper indicated that even though some of the errors are preventable, it is quite unlikely that that be totally eliminated since they are caused by human errors (Kohn et al., 2000).There is generally a lack of strong evidence in the existing iterature on the feeling of nurses in regard to the factors that contribute to the stated medication errors. Most of the studies were conducted in the United States and were tended to be conducted by non-nurse except the ones by Hand and Barber (2000), King (2004), Gladstone (1995) and Hand and Barber (2000 ) who felt that the experiences of the nurses as well as their knowledge were generally undervalued.

Kliger J, Blegen MA, Gootee D, O'Neil E. (2009).Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J. Qual Patient Saf. 2009 Dec;35(12):604-12.

In this paper, Klinger et al. (2009) carried out a study in 7 hospitals located in the San Francisco Bay Area.The hospitals took part in am eighteen month long integrated Nurse Leadership Program that was designed to help in the improvement of the reliability of the administration of medication through the development as well as deployment of nurse leadership as well as process improvement skills on a medical inpatient unit.

The study involved the formation of nurse0led projects in each hospital that operated on 6 safety procedures in order to improve the accuracy of the medication administration. These were then compared to the existing records on medication administration. The other activitie scarrie dout were the keeping of the medication records that are labeled from the preparation of administration as well as chcking of 2 forms of the patient identification. There was also an explanation to the patients and immediate charting. The process was also protected from interruptions and distractions.

The results revealed that for 6 hospitals that were part of the analysis, the accuracy of the process of medication administration improved from eighty five percent in the baseline period to ninety two percent 6 months after the intervention and another ninety six percent after the intervention.

This study suggested that the frontline nurses as well as other hospital staff if provided with training, authority and resources are poised to lead to an improvement of the patient care as well as safety processes.

Pape TM. (2003)Applying airline safety practices to medication administration. Medsurg Nurs. 2003 Apr;12(2):77-93; quiz 94.

In this paper, Pape (2003) discusses how the application of airline safety practices to the concept of medication administration is carried out. He points out that Medication administration errors (MAE) have continued to be a source of problems for various health care institutions, patients as well as nurses. He pointed out that Medication administration errors (MAE) are usually a result of system failures that leads to patient injury, elevation in hospital costs as well as blaming. The costs include the ones associated with long stay in hospital as well as legal expenses. The contributing factors include poor communication distraction, failure to follow the standard operating procedure as well as lack of focus during the process of medication administration.

Evans J.(2009).Prevalence, risk factors, consequences and strategies for reducing medication errors in Australian hospitals: a literature review. Contemp Nurse. 2009 Feb;31(2):176-89.

In this paper, the author investigates the prevalence, risk factors, consequences as well as strategies to be used in the education of medication errors In various hospitals. The purpose of the paper is to examine the various medication errors form the perspective of the nurse. The work provides a detailed overview of the past as well as current literature in the examination of the prevalence rates as well as risk factors for the various medication costs. The work provides a description of the injury as well as harm that is associated with instances of medication errors. The paper also proposes strategies necessary to counteract them. According to this study, close to 2% of patients in various acute care settings are likely to experience medication errors. The administration of medication is therefore a high risk task for various registered nurses and therefore the strategies for mitigating the errors for this paper is largely nursing focused. The case of medication errors are on the rise in various health care settings. The advent of technology as well as pharmaceutical advances has been noted to make the environment of medication administration increasingly complex. The nature of medication therapoy makes it practically impossible to eliminate all forms of errors.

Johnson M, Young H. J (2011)The Application of Aronson's Taxonomy to Medication Errors in Nursing. J Nurs Care Qual .Vol. 26, No. 2, pp. 128 -- 135

In this paper, the concept of medication administration is noted to be a frequent nursing activity. A total of three hundred and eighteen self-reported incidents were considered. .Aronson's classification system was employed for the purpose of providing a framework to be used for the analysis of various incidents having a close connection between the change strategy and type of error. The paper pointed out that the use of behavioral approaches to take care of medication errors has provided useful strategies for nurses.

Relihan E, O'Brien V, O'Hara S, Silke B.(2010)The impact of a set of interventions to reduce interruptions and distractions to…

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