QUALITY IMPROVEMENT

Evidence-Based Practice for Reducing Medication Errors

The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as a preventable event that may lead to patient harm or inappropriate medication use while the medication is in the control of the consumer, patient, or healthcare professional (Federwisch et al., 2014). According to the Institute of Medicine (IOM), approximately 1.5 million adverse events that could have been prevented occur in the US every year due to medication errors (Federwisch et al., 2014). It is estimated that medication-related errors cost US hospitals approximately $3.5 billion annually, with each event increasing hospital costs by at least $5,857 (Federwisch et al., 2014).

The article under review focuses on the efforts of a 35-bed pulmonary-medical unit that consistently reported a high number of medical errors as many as 21 in one quarter to reduce the same (Federwisch et al., 2014). The nursing leadership at the facility first conducted a review of unit-specific information and incident reports to identify the most common causes of medication errors. The review showed that most medication errors occurred due to distractions and interruptions during administration. Healthcare professionals committed twice as many medication errors when interrupted than when there were no distractions or interruptions (Federwisch et al., 2014). Family members enquiries, physicians and patients requests, alarms, and site occlusions were the most common sources of interruption (Federwisch et al., 2014).

In this regard, the hospital initiated a program mimicking the aviation industry sterile-cockpit rule, which forbids non-essential activity and conversations among crew members during takeoff, taxiing, and landing (Federwisch et al., 2014). The hospital conducted research to explore how different nursing units had adopted the sterile cockpit rule and assess the efficacy of their strategies. Hospitals had used a range of strategies in applying the rule, including designating no-interruption zones by affixing red duct tape to the floor...…causes. Data gathered from incident reports showed that most errors occurred due to interruptions during medication administration. Further research was conducted to obtain data on the specific strategies that had been adopted by other hospitals to minimize these disruptions and the effectiveness of the same.

DEVELOP from the data that had been gathered and analyzed, the nursing leadership formulated an action plan that included limiting communication and disruptions during administration (Medication Quiet Time) and bedside rounding.

EXECUTE - Red signs were placed on medication carts warning other healthcare staff and members of the public to keep off during administration and unit secretaries were recruited to minimize the number of telephone calls made to nurses during administration.

EVALUATE follow-up surveys were conducted with the unit secretaries and nurses to evaluate the effectiveness of the program. Identified problems were addressed through the provision of coaching services to nursing staff facing adherence challenges. At the end of the period, the…