Clinical Application Project and E- Poster

Reducing Medication Errors by Nursing Staff

Problem • A medical surgical unit manager has had a significant increase in medication administration errors over the last two months. The errors involve many staff members and are occurring on all shifts. The budget does not allow for the

purchase of a new administration system.

• Medication errors in hospital settings create a serious threat to patient safety, and it can be challenging to implement strategies that are effective at reducing

incidents.

• Our goal is to propose an evidence-based plan within the parameters of this unit to decrease medication administration errors from the nursing staff .

Our Goal

Strengths •A diverse committee is

most successful at reducing medication error

rates (Hanifin & Zielenski,

2020).

•The nurses and managers were willing to

participate in the error reduction program

(Johnson et al., 2017).

•Using the HALT method to check if a nurse was

hungry, angry, lonely, late, or tired reduced

medication errors by 31% (Ragau et al., 2018).

•The methods implemented were

inexpensive and easy to use (Raja et al., 2019).

Weaknesses

•Nurses were interrupted during 98% of all

observed medication administration events (Johnson et al., 2017).

•There is a significant connection between

nurse interruptions and medication errors (Raja

et al., 2019).

•Of all the interruptions observed on the unit,

39% were from one nurse to another (Johnson et al.,

2017).

•A nurse with unmet needs is more likely to

make a medication error (Ragau et al., 2018).

Opportunities

•A unit observer will help to identify the medication errors

(Johnson et al., 2017).

•Evenly distributed workloads reduce medication errors

(Raja et al., 2019).

•The HALT method can be taught at staff meetings (Ragau et

al., 2018).

•Reminder posters were effective at

reducing medication errors (Johnson et al.,

2017).

Threats

•Medication errors can cause patient injury and

mortality (Johnson et al., 2017).

•Low patient satisfaction will cause

the hospital to lose business (Ragau et al.,

2018).

•Medication errors diminish the

confidence of the nurse and lower unit morale (Ragau et al., 2018).

•Medication errors increase institutional

costs (Raja et al., 2019).

Assessment

• Out of all medication administration events on the unit, 98% had interruptions (Johnson et al., 2017).

• Nurses were the source of 39% of interruptions to other nurses during medication administration (Johnson et al., 2017).

• Negative emotions and sensations experienced by nurses contribute to medication errors (Ragau et al., 2018).

• A multidisciplinary committee is most effective at reducing medication errors (Hanifin & Zielenski, 2020).

Diagnosis

SMART Goal

• Our goal is to appoint a multidisciplinary committee that will train staff to use evidence-based interventions, such as reducing interruptions during medication administration, to reduce medication errors on the unit by 25% within 2 months.

Transactional/Transformational Leadership

Transactional

• Committee will analyze data to determine causes of errors

• Committee will create an educational packet outlining rules and regulations

• Managers will give verbal and written warnings for not following policies

• Managers will do rounds to enforce the interruption guidelines and HALT method

Transformational

• Data will be analyzed for opportunities for growth

• The committee will convince staff to believe in the goal

• Staff will be empowered with education and positive feedback

• Nurses will learn from each other

Each of these styles have important principles, but they must be combined to best

achieve our goal

Plan: Month One

Day 1

Appoint a diverse committee to identify the sources of medication errors on the unit and to research the most suitable EBPs to correct the problem.

End of week one

1st in-service meeting with unit staff and representatives from other specialties to teach them the causes of medication errors and strategies to reduce them

Daily reinforcement

of teachings at shift changes and throughout day, with recognition of small successes

Week 3

2nd in-service meeting to assess strengths and weaknesses of plan. Encourage staff feedback.

Use positive reinforcement to empower and reward improvement. Address areas that need work.

Week 4

Committee meeting to evaluate the medication error statistics for the past month. Aim to decrease errors by 10%

Compare to previous months. Identify ways to reinforce areas of weakness. Rework plan as needed.

Plan: Month Two

Week 5

Present findings to unit to praise and reinforce favorable behavior; present remediation plan if goal is not met. Use incidents as a group learning opportunities.

Daily reinforcement

During change of shift meeting, throughout the day and with fresh visual reminders. Encourage staff feedback.

Week 6

The committee will continue to monitor the performance of the unit through informatics and daily observation.

Week 8:

Aim to decrease medication errors by 25%.

At the end of the month, the committee will assess the effectiveness of program. Decide if goal was successfully met. Present findings to staff at all levels.

Implementation: Lewin’s Change Theory (Marquis & Huston, 2017)

• Unfreezing

The committee will review data to diagnose the problem and agree that improvement in medication error rates is needed.

The committee will present at in-service and discuss medication errors ONLY to create discontent.

• Movement

Inspire staff to want to improve rates.

Set small, medium and larger goals.

Implement changes as discussed in plan.

Make change a priority! Address resistance to change daily, and in the 2 main in-service meetings.

Build trust in the committee’s expertise and among staff.

• Refreezing

This usually takes at least 3 months. After the changes have been determined to be successful, they can start to become the status quo.

Evaluation Desired Outcome Actual Outcome Maintain Goals and

Desired Outcome

-To decrease number of medication errors on the unit by 25%.

-Nurses will increase self-awareness.

-Team will increase awareness of

staff at risk of errors.

-Team will share the common goal of

reducing medication errors on unit .

-The interruptions between nurse to nurse

were observed by 39% during medication

administration (Johnson et al., 2017).

-Medication errors were decreased by

31% after implementation of HALT

method (Ragau et al., 2018).

-Researchers found that error rates

decreased from 6.7% to 3.6% after

interventions

(Hanifin & Zielenski, 2020).

-Nurses at the bedside need to be actively

involved in solutions.

(Hanifin & Zielenski, 2020).

-Continuous monitoring and education for

nurses regarding medication errors (Johnson

et al., 2017).

- Evaluate medication errors in a

nonpunitive manner when appropriate

(Hanifin & Zielenski, 2020).

-Predict where shortfalls will occur in

medication administration (Ragau et al.,

2018)

-Safer medication use on unit with low error

rate (Raja et al., 2019)

-Periodic policy evaluation (Raja et al.,

2019).

Implementation Barriers

• Competing demands (Johnson et al., 2017).

• Change is usually met with resistance (Marquis & Huston, 2017).

• Different backgrounds and experiences (Ragau et al., 2018).

• Innate human error (Hanifin & Zielenski, 2020).

• Providing adequate nursing staff (Raja et al., 2019).

Questions to Think About

• Is it possible to reach 0% error rates?

• Will old habits return after goals have been met?

• How can nurses balance multitasking while administering medication?

References

Hanifin, R. & Zielenski, C. (2020). Reducing medication error through a collaborative committee structure: An effort to implement change in a community-based health system. Quality Management in Health Care, 29(1), 40-45. https://doi.org/10.1097/QMH.0000000000000240

Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: An observational study of nurses. Journal of Nursing Management, 25(7), 498-507. https://doi.org/10.1111/jonm.12486

Marquis, B.L., & Huston, C. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed). Wolters Kluwer. ISBN-13: 978-1-975139-21-6

Ragau, S., Hitchcock, R., Craft, J., & Christensen, M. (2018). Using the HALT model in an exploratory quality improvement initiative to reduce medication errors. British Journal of Nursing, 27(22), 1330–1335. https://doi-org/10.12968/bjon.2018.27.22.1330

Raja, Badil, Ali, S., & Sherali, S. (2019). Association of medication administration errors with interruption among nurses in public sector tertiary care hospitals. Pakistan Journal of Medical Sciences, 35(5), 1318–1321. https://doi.org/10.12669/pjms.35.5.287