Implementation/intervention | Science

LiteratureRevie1.edited14.docx

1

Literature Review: Impact of Reconciliation-Based Intervention on Medication Error Reduction

Student’s name

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Literature Review: Impact of Reconciliation-Based Intervention on Medication Error Reduction

Nguyen et al. (2022) conducted a study on how intervention by the reconciliation process from an intern pharmacist will reduce medication errors in discharge summations. The study investigated whether intern pharmacists' examining drug data in discharge summaries and reconciling them with prescribed pharmaceuticals indirectly reduces prescription errors by alerting physicians to discrepancies. researchers developed a retrospective review to compare medication information for DSs with discharge prescription and considered it the ‘source of truth’. They then identified high-risk errors using a classification using a modified APINCH system and measured time taken for intervention. 22 patients who had received intervention were compared with 31 control cases and were discharged from similar wards, for different periods of time.

The intervention patients experienced decrease in medication errors when compared to the control group. In addition, fewer numbers of patients under the intervention had at least one drug charting error on their DSs for both global and high-risk medications. Over the course of the intervention, 77 recommendations related to high-risk medications were made by the intern pharmacist at 8%. It also took a relatively short time to have this intervention done, with median times of 4 minutes for initial review and 1 minute for re-review (Nguyen et al., 2022). Consequently, according to this study, intern pharmacist-based reconciliation can help reduce medication errors on DSs.

Nguyen et al. (2022) is relevant to evaluating the effect of patient education materials on reducing medication errors. It demonstrates how a targeted intervention may reduce medication mistakes made during the discharge phase. The research highlights how an intern pharmacist reviewing DSs and matching them with discharge prescriptions may improve drug safety during care transfer. Coordinated strategies have been found to be effective in improving accuracy of information on drugs related to DS (Nguyen et al., 2022). Multidisciplinary healthcare teams should thus facilitate reconciliation for the benefit of patients.

References

Nguyen, A., Gibson, S., & Wembridge, P. (2022). Improving medicine information on discharge summaries through the implementation of a reconciliation‐based intervention. Journal of Pharmacy Practice and Research. https://doi.org/10.1002/jppr.1828

FinalProjectQI.docx

Final Project: Implementation of Intervention

The proposed intervention to help reduce falls in the neuro tele unit, will be hourly rounding. Hourly rounding limits patient falls by providing around the clock check ins on patients and provides “an opportunity to ensure that universal fall precautions are implemented, and that patients’ needs are being met” (Spano-Szelkey et al., 2019, pg. 128). This will limit the occurrence of patients attempting to independently walk or move on their own with the possibility of harming themselves by falling. The nurse will primarily be responsible to ensure rounding is occurring but will share the task of rounding with the patient care techs. To evaluate if this intervention is working the management team will compare falls data 3-months pre-implementation to the 3-months post-implementation following the hourly rounding. The goal of this project will be to improve the fall rate by 4%. This project will create compliance among the team and provide accountability to adhere to rounding schedule by the nurse and the patient care tech, as mentioned by Spano-Szelkey et al. (2019) fall prevention should be a team effort, anyone that provides care for the patient should be involved.

In the beginning leadership will propose this project to the staff and gather their input. It is important to grasp the input of the nurses and the techs since they will be implementing this project and they have the most patient contact. Once majority of the team is onboard, the staff will be taught how to correctly hourly round, the nurse and the patient care tech will alternate hours of rounding, for example the nurse might round at the even hours and the patient care tech will round at the odd hours of the day. When rounding the staff will check in on assigned patients, asking patients if they need anything more specifically asking if they need to go the bathroom or would like to move to a chair. According to Hendrich (2021) rounding should be individualized based on the patient’s values and goals, for example with a patient that has a low fall risk the staff might want to walk next to the patient as a precaution. The implementation is individualized to avoid shifting a patient’s mobility skills backwards, the focus should be promoting mobility and independence for the patients.

To ensure the team is rounding, daily rounding sheets will be placed on each patient’s door. The sheets will include patient’s name, room number, date, and hours. The sheets will have slots for each hour starting at midnight and ending at 2300 the next evening, the night shift nurse will replace the sheet at midnight starting a new sheet for the date. In the slot the nurse or the tech will signify their initials into the slot once they have rounded on that patient for that hour. If an hour was missed, it should be documented with the reason why, for example if a patient is off unit for a CT scan that should be noted on the rounding sheet. These sheets will be stored on the nursing unit until management deems compliance and accountability have been established then they may be discarded.

After the three-month period of implementation management will evaluate the effectiveness of the intervention. Fall rates should be decreased by 4% and or trending downward. If they are not trending downward leadership will reassess if the staff is correctly implementing hourly rounding by providing reeducation, online training modules or through the teach-back method. If any issues are identified by leadership regarding the rounding process, they will look at the hourly rounding sheets to see if rounding is getting missed and figure out the reasoning behind the missed care, so they are able to find a resolution to the problem. Once at the 4% benchmark is met, this project will conclude, and hourly rounding will be part of patient care on the unit.

Conclusion

Provide a substantive conclusion for your paper, it will include: the problem or issue restated, the solution or intervention briefly summarized, and the final impact the change had on the unit and or nursing in general.

LiteratureRevie1.edited14.docx

1

Literature Review: Impact of Reconciliation-Based Intervention on Medication Error Reduction

Student’s name

Institutional Affiliation

Course name

Professor’s name

Due date

Literature Review: Impact of Reconciliation-Based Intervention on Medication Error Reduction

Nguyen et al. (2022) conducted a study on how intervention by the reconciliation process from an intern pharmacist will reduce medication errors in discharge summations. The study investigated whether intern pharmacists' examining drug data in discharge summaries and reconciling them with prescribed pharmaceuticals indirectly reduces prescription errors by alerting physicians to discrepancies. researchers developed a retrospective review to compare medication information for DSs with discharge prescription and considered it the ‘source of truth’. They then identified high-risk errors using a classification using a modified APINCH system and measured time taken for intervention. 22 patients who had received intervention were compared with 31 control cases and were discharged from similar wards, for different periods of time.

The intervention patients experienced decrease in medication errors when compared to the control group. In addition, fewer numbers of patients under the intervention had at least one drug charting error on their DSs for both global and high-risk medications. Over the course of the intervention, 77 recommendations related to high-risk medications were made by the intern pharmacist at 8%. It also took a relatively short time to have this intervention done, with median times of 4 minutes for initial review and 1 minute for re-review (Nguyen et al., 2022). Consequently, according to this study, intern pharmacist-based reconciliation can help reduce medication errors on DSs.

Nguyen et al. (2022) is relevant to evaluating the effect of patient education materials on reducing medication errors. It demonstrates how a targeted intervention may reduce medication mistakes made during the discharge phase. The research highlights how an intern pharmacist reviewing DSs and matching them with discharge prescriptions may improve drug safety during care transfer. Coordinated strategies have been found to be effective in improving accuracy of information on drugs related to DS (Nguyen et al., 2022). Multidisciplinary healthcare teams should thus facilitate reconciliation for the benefit of patients.

References

Nguyen, A., Gibson, S., & Wembridge, P. (2022). Improving medicine information on discharge summaries through the implementation of a reconciliation‐based intervention. Journal of Pharmacy Practice and Research. https://doi.org/10.1002/jppr.1828

FinalProjectQI.docx

Final Project: Implementation of Intervention

The proposed intervention to help reduce falls in the neuro tele unit, will be hourly rounding. Hourly rounding limits patient falls by providing around the clock check ins on patients and provides “an opportunity to ensure that universal fall precautions are implemented, and that patients’ needs are being met” (Spano-Szelkey et al., 2019, pg. 128). This will limit the occurrence of patients attempting to independently walk or move on their own with the possibility of harming themselves by falling. The nurse will primarily be responsible to ensure rounding is occurring but will share the task of rounding with the patient care techs. To evaluate if this intervention is working the management team will compare falls data 3-months pre-implementation to the 3-months post-implementation following the hourly rounding. The goal of this project will be to improve the fall rate by 4%. This project will create compliance among the team and provide accountability to adhere to rounding schedule by the nurse and the patient care tech, as mentioned by Spano-Szelkey et al. (2019) fall prevention should be a team effort, anyone that provides care for the patient should be involved.

In the beginning leadership will propose this project to the staff and gather their input. It is important to grasp the input of the nurses and the techs since they will be implementing this project and they have the most patient contact. Once majority of the team is onboard, the staff will be taught how to correctly hourly round, the nurse and the patient care tech will alternate hours of rounding, for example the nurse might round at the even hours and the patient care tech will round at the odd hours of the day. When rounding the staff will check in on assigned patients, asking patients if they need anything more specifically asking if they need to go the bathroom or would like to move to a chair. According to Hendrich (2021) rounding should be individualized based on the patient’s values and goals, for example with a patient that has a low fall risk the staff might want to walk next to the patient as a precaution. The implementation is individualized to avoid shifting a patient’s mobility skills backwards, the focus should be promoting mobility and independence for the patients.

To ensure the team is rounding, daily rounding sheets will be placed on each patient’s door. The sheets will include patient’s name, room number, date, and hours. The sheets will have slots for each hour starting at midnight and ending at 2300 the next evening, the night shift nurse will replace the sheet at midnight starting a new sheet for the date. In the slot the nurse or the tech will signify their initials into the slot once they have rounded on that patient for that hour. If an hour was missed, it should be documented with the reason why, for example if a patient is off unit for a CT scan that should be noted on the rounding sheet. These sheets will be stored on the nursing unit until management deems compliance and accountability have been established then they may be discarded.

After the three-month period of implementation management will evaluate the effectiveness of the intervention. Fall rates should be decreased by 4% and or trending downward. If they are not trending downward leadership will reassess if the staff is correctly implementing hourly rounding by providing reeducation, online training modules or through the teach-back method. If any issues are identified by leadership regarding the rounding process, they will look at the hourly rounding sheets to see if rounding is getting missed and figure out the reasoning behind the missed care, so they are able to find a resolution to the problem. Once at the 4% benchmark is met, this project will conclude, and hourly rounding will be part of patient care on the unit.

Conclusion

Provide a substantive conclusion for your paper, it will include: the problem or issue restated, the solution or intervention briefly summarized, and the final impact the change had on the unit and or nursing in general.