Chang Proposal - Milestone #4 [Type Text]

¶ … Chang Proposal - Milestone #4

[Type text] [Type text] [Type text]

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).

Step 3: Synthesize the Best Evidence

Research on the distraction-induced error rates of medication administration can be roughly categorized by studies that have addressed: 1) nursing staff attributes and institutional work context, 2) modification of systems and procedures, and 3) stakeholder-inclusive educational programs. Important studies from each of these categories are discussed below.

Westbrook, et al. (2010) controlled for the work status and experience of nurses in their study on the association of interruptions with increased risk and severity of medication administration errors. While nursing experience and status were not found to be related to risk of clinical errors, work status was related, with part-time nurses had lower rates of procedural error (Westbrook, et al., 2010). Westbrook's (2009) research found that experienced nurses tended to be confident in their ability to recognize patients, but this recognition factor did not mean that the nurses were referring to the correct patient chart. An intervention strategy that reduced this source of medication-patient identity error from 17.4% to 82.4% was introduced by Franklin, et al. (2007) with the use of barcodes for patient medications.

O'Brien (2010) found that changing the environment and communicating with stakeholders reduced the chance of medication administration errors. Operating room staff receives additional training in the management of distraction and a range of safety-related psychological skills (Mitchell and Flin, 2008). Recognition of the potential positive impact of standardized procedures and explicit training for dealing with interruptions and ensuring accurate administration of medication to patients resulted in the study by Hughes and Blegen (2008), in which the researchers created and evaluated an evidence-based medication handbook for nurses. Craig, et al. (2013) found that the number of overall interruptions declined when nurses wore a white vest worn during medication administration and imprinted with the words: "Please do not interrupt while passing medications." Relihan, et al. (2010) developed and tested a multifactorial set of interventions in a 1000-bed teaching hospital; the results showed a significant reduction in the interruption / distraction rate for five of 11 categories evaluated.

Step 4: Design Practice Change

The proposed practice change will be a multifactorial intervention that includes these important prongs: 1) Establishment of a distraction free zone for the preparation and administration of medication; 2) during medication rounds, nurses administering medications will wear disposal (red) sashes or vests to signal that they are not to be interrupted without unavoidable substantive cause; 3) use of a checklist that ensures the medication administration system is ready for the imminent medication round; 4) educational sessions with nursing staff and other stakeholders; 5) briefing -- where appropriate -- and the provision of explanatory brochures to patients; and 6) establishing a committee to address the practice problem locally "by encouraging the generation, trial, and iterative development of solutions directly by the nursing workforce" as recommended by Young and McClean (2008).

Step 5: Implement and Evaluate the Change in Practice

The change of practice will be driven by the content provided through the educational sessions with staff. The fundamental goal of the practice change is to reduce medication administration errors by improving staff awareness of the practice problem, establishing new behaviors to safeguard the change of practice, and to standardize clinical actions in order to facilitate the collection of data related to the fidelity of implementation and the reduction in the error rate of medication errors.

Implement & Evaluation Plan

The educational sessions will be conducted with nursing staff as part of the shift pass-down, as orientation of newly hired staff, and as a component of the routine staff training periodically conducted with teams. A special educational session will be conducted within two weeks of the change plan completion and approval. The checklist that will guide nursing staff to head off system issues will initially be based on the recommendations of Relihan, et al. (2010), and includes items such as: 1) Ensuring the medication trolley is stocked with any needed supplies prior to each medication round; 2) announcing the commencement of a medication round to colleagues; 3) instructing nursing students and naive observers to withhold comment or questions that are not directly impactful of the administration of medication; 4) donning the agreed upon signal apparel (red vest or sash) when preparations have been made; 5) closing doors and using "Do Not Disturb" signage on access doors where appropriate; 6) avoiding the initiation of unrelated communication with others during the medication round; 7) directing any interrupters to colleagues who are not administering medication; and, 8) addressing all instances of missing medications at one time -- at the end of the medication round (Relihan, et al., 2010).