Reducing Medication Errors Quality Improvement

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 around medication carts, having nurses wear yellow safety vests to alert their colleagues that medication administration was ongoing and the nurse was not to be interrupted, and placing ‘Do not Disturb’ signs above medication carts and dispensing machines (Federwisch et al., 2014). The findings indicated that the strategies effectively reduced the frequency of interruption by 40.9, 52, and 27 percent (Federwisch et al., 2014). However, the wearing of vests had attracted significant resistance from nurses, who found it difficult to wear their vests at the right time.

With this information, the hospital administrators decided on a two-pronged strategy that incorporated: i) change-of-shift bedside rounding and ii) variation of the sterile-cock rule to limit communication during administration as a way of minimizing distractions (Federwisch et al., 2014). The specific strategies that were adopted to limit communication included: using red signs bearing the text ‘Stop!!Medication Administration is in Progress; Do not Disturb’ on medication carts and recruiting unit secretaries to evaluate the requests of callers and route calls to nurses only when necessary (Federwisch et al., 2014). Bedside rounding brought together the incoming and outgoing nurses at the patient’s bedside during shift changes to verify that medications/fluids were infusing as required, and to check catheter sites, mental status, and identification bracelets for errors (Federwisch et al., 2014).

Two months after the initiation of the program, the nursing leadership conducted a follow-up survey to evaluate the program’s effectiveness (Federwisch et al., 2014). The survey included 32 nurses, 31 percent of whom reported an improvement in the frequency of interruptions with the implementation of the program, while 66 percent reported no change (Federwisch et al., 2014). The nursing leadership refined the program and offered coaching to staff members who were having issues with adherence. Another follow-up survey was conducted several months later, with 75 percent of nurses reporting that the frequency of interruptions had reduced (Federwisch et al., 2014). Data collected from incidence reports indicated that the number of medication errors reduced from 42 in the previous year to only 23 in the year of the program’s implementation, despite the number of medications administered almost doubling (Federwisch et al., 2014).

The QI model adopted corresponds to the FADE QI model in the readings:

FOCUS – the nursing leadership identified the high occurrence of preventable medication errors as a problem and a potential risk to patient safety

ANALYZE – research was conducted to ascertain the extent of the problem and the specific 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.