Other Titles
Controlled Substance Handoff [Poster Title]
Abstract
Purpose: Ensuring the safe handoff of controlled substances during patient transfers is critical in pediatric emergency care. Recognizing gaps in documentation and chain-of-custody processes, this nurse-led initiative aimed to design an innovative, technology-driven approach to enhance patient safety and ensure compliance with regulatory standards. The project focused on integrating advanced tools to streamline workflows, minimize errors, and safeguard pediatric patients.
Methods: A multidisciplinary team, led by pediatric emergency nurses, collaborated to develop a documentation framework leveraging existing health technology. The team adapted the Epic Rover mobile application and electronic medical record (EMR) systems to enable real-time documentation of controlled substances during transitions of care. Trial runs were conducted to assess feasibility, focusing on workflow integration, double-check processes for controlled substances, and capturing infusion details such as rates and remaining volumes. Nurses served as key drivers of workflow design, ensuring the solution aligned with clinical needs while adhering to safety protocols.
Implementation: The solution included a customized Medication Administration Record (MAR) action within the EMR, allowing seamless documentation of controlled substance handoffs, including infusion rates, remaining volumes, and verification by receiving care team members. A training program was developed to ensure nursing staff proficiency in the new workflow, emphasizing the role of double-checks for controlled substances. Multidisciplinary collaboration across nursing, pharmacy, and informatics teams ensured that the implementation met both clinical and regulatory standards.
Implications: This initiative demonstrates the critical role of nursing leadership in identifying gaps, designing innovative solutions, and driving technology integration in clinical practice. By ensuring accurate documentation and compliance for controlled substance handoffs, this project highlights the potential for scalable and generalizable solutions to enhance patient safety in pediatric emergency care settings. It underscores the importance of interdisciplinary collaboration in addressing complex clinical challenges and optimizing workflows through technology. Lessons learned from this initiative may inform broader efforts to enhance the safety of controlled substance handoffs across diverse healthcare settings.
Notes
References:
Benjamin, L., Frush, K., Shaw, K., Shook, J. E., & Snow, S. K. (2018). Pediatric Medication Safety in the Emergency Department. Annals of Emergency Medicine, 71(3), e17-e24. https://doi.org/10.1016/j.annemergmed.2017.12.013
Joseph, M. M., Mahajan, P., Snow, S. K., Ku, B. C., & Saidinejad, M. (2022). Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics, 150(5). https://doi.org/10.1542/peds.2022-059673
Marufu, T. R., Bower, R. R., Hendron, E., & Manning, J. R. (2022). Nursing interventions to reduce medication errors in paediatrics and neonates: Systematic review and meta-analysis. Journal of Pediatric Nursing, 62, e139-e147. https://doi.org/10.1016/j.pedn.2021.08.024
Motulsky, A., Wong, J., Cordeau, J. P., Pomalaza, J., Barkun, J., & Tamblyn, R. (2017). Using mobile devices for inpatient rounding and handoffs: an innovative application developed and rapidly adopted by clinicians in a pediatric hospital. Journal of the American Medical Informatics Association, 24(e1), e69-e78. https://doi.org/10.1093/jamia/ocw107
Samuels-Kalow, M. E., Tassone, R., Manning, W., Cash, R., Davila-Parrilla, L., Hayes, B. D., Porter, S., & Camargo, C. A., Jr. (2024). Analysis of a Medication Safety Intervention in the Pediatric Emergency Department. JAMA Netw Open, 7(1), e2351629. https://doi.org/10.1001/jamanetworkopen.2023.51629
Sigma Membership
Alpha Alpha Lambda at-Large
Type
Poster
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Other
Keywords:
Interprofessional and Interdisciplinary, Acute Care, Interprofessional Initiatives, Clinical Practice, Technology in Practice, Handoff, Pediatric Emergency Patients
Recommended Citation
Catterson, Lindsey; Revet, Jessica; and Alzawad, Zainab, "Enhancing Pediatric Emergency Medication Safety with Nurse-Led Innovation and Technology" (2025). Biennial Convention (CONV). 74.
https://www.sigmarepository.org/convention/2025/posters_2025/74
Conference Name
48th Biennial Convention
Conference Host
Sigma Theta Tau International
Conference Location
Indianapolis, Indiana, USA
Conference Year
2025
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2025-12-06
Enhancing Pediatric Emergency Medication Safety with Nurse-Led Innovation and Technology
Indianapolis, Indiana, USA
Purpose: Ensuring the safe handoff of controlled substances during patient transfers is critical in pediatric emergency care. Recognizing gaps in documentation and chain-of-custody processes, this nurse-led initiative aimed to design an innovative, technology-driven approach to enhance patient safety and ensure compliance with regulatory standards. The project focused on integrating advanced tools to streamline workflows, minimize errors, and safeguard pediatric patients.
Methods: A multidisciplinary team, led by pediatric emergency nurses, collaborated to develop a documentation framework leveraging existing health technology. The team adapted the Epic Rover mobile application and electronic medical record (EMR) systems to enable real-time documentation of controlled substances during transitions of care. Trial runs were conducted to assess feasibility, focusing on workflow integration, double-check processes for controlled substances, and capturing infusion details such as rates and remaining volumes. Nurses served as key drivers of workflow design, ensuring the solution aligned with clinical needs while adhering to safety protocols.
Implementation: The solution included a customized Medication Administration Record (MAR) action within the EMR, allowing seamless documentation of controlled substance handoffs, including infusion rates, remaining volumes, and verification by receiving care team members. A training program was developed to ensure nursing staff proficiency in the new workflow, emphasizing the role of double-checks for controlled substances. Multidisciplinary collaboration across nursing, pharmacy, and informatics teams ensured that the implementation met both clinical and regulatory standards.
Implications: This initiative demonstrates the critical role of nursing leadership in identifying gaps, designing innovative solutions, and driving technology integration in clinical practice. By ensuring accurate documentation and compliance for controlled substance handoffs, this project highlights the potential for scalable and generalizable solutions to enhance patient safety in pediatric emergency care settings. It underscores the importance of interdisciplinary collaboration in addressing complex clinical challenges and optimizing workflows through technology. Lessons learned from this initiative may inform broader efforts to enhance the safety of controlled substance handoffs across diverse healthcare settings.
Description
This nurse-led initiative leveraged advanced health technology to improve documentation and safety during controlled substance handoffs in pediatric emergency care. By integrating real-time workflows and emphasizing interdisciplinary collaboration, the project highlights nursing leadership's critical role in advancing patient safety and optimizing clinical workflows. This approach offers scalable solutions for improving controlled substance handoffs across diverse healthcare settings.