Abstract
Session C presented Thursday, September 27, 1:00-2:00 pm
Purpose: Many nurses struggle with the recognition and reporting of unsafe practices, most notably medication administration (Weant et al., 2014). Reasons identified range from knowledge deficit, to fear of reporting (Weant et al., 2014). This evidence-based practice (EBP) change focused on improving medication error recognition and reporting by ED nurses through utilizing leader rounding and coaching to facilitate a culture of safety, transparency, and learning.
Design: A pre-post measurement design was used in this project. Nursing attitudes toward reporting the type of medication errors, as well as the number reported before and after coaching, education and leadership support are provided. Data was obtained via employee engagement survey questions administered in 2015, and then again in the summer of 2017.
Setting: The project site involves three EDs of a health network in Southeastern North Carolina. The main facility is a 647-bed acute care hospital and regional Trauma Center serving a seven-county area near the coast, the other two facilities include a 80 bed orthopedic hospital and a 12 bed standalone ED.
Participants/Subjects: Potential project participants are 133 Emergency Nurses working in any one of the three network EDs. All participants will be adults 18 years of age or older including all genders and ethnicities. Participants to be included consist of ED nurses that have worked in at least one of the three departments for at least 120 days before the implementation of the project.
Methods: An educational program was developed and administered to the nursing and paramedic staff at each of the project site EDs. A blended approach consisting of face to face and online learning was used. Concepts that were covered in the program included recognition of medication errors and adverse drug events, practices that contribute to medication errors including interruptions during administration, and failure to utilize the existing medication barcode system which studies have shown decreases the number of administration errors (Agency for Healthcare Research and Quality [AHRQ], 2015).
Results/Outcomes: Results of the implementation were mixed, and although some improvements were made, the education, observation and clinical coaching did not have the impact that was anticipated at the beginning of the project. A lack of staff engagement, as noted by participation percentages may have influenced the results. It is important to note that during the time of implementation, two of the three EDs were experiencing record high census and increased hours of inpatient boarding at all three campuses, stretching the abilities of staff to participate in projects. The increased census, combined with continued demands to accommodate all patients quickly and safely, further validated the need for this practice change project to be implemented as previously discussed by Affleck, Parks, Drummond, Rowe, and Ovens (2013).
Implications: This evidence-based project raised awareness and demonstrated that there were opportunities to improve the recognition and reporting of medication errors that occur not only in the ED, but elsewhere in the targeted organization. Increased focus on the need for further development of a culture of safety.
Sigma Membership
Non-member
Type
Poster
Format Type
Text-based Document
Study Design/Type
N/A
Research Approach
N/A
Keywords:
Medication Errors, Culture of Safety, Safety Reporting
Recommended Citation
DeWees, Terri, "Recognition and reporting of medication errors" (2019). General Submissions: Presenations (Oral and Poster). 113.
https://www.sigmarepository.org/gen_sub_presentations/2018/posters/113
Conference Name
Emergency Nursing 2018
Conference Host
Emergency Nurses Association
Conference Location
Pittsburgh, Pennsylvania, USA
Conference Year
2018
Rights Holder
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Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Recognition and reporting of medication errors
Pittsburgh, Pennsylvania, USA
Session C presented Thursday, September 27, 1:00-2:00 pm
Purpose: Many nurses struggle with the recognition and reporting of unsafe practices, most notably medication administration (Weant et al., 2014). Reasons identified range from knowledge deficit, to fear of reporting (Weant et al., 2014). This evidence-based practice (EBP) change focused on improving medication error recognition and reporting by ED nurses through utilizing leader rounding and coaching to facilitate a culture of safety, transparency, and learning.
Design: A pre-post measurement design was used in this project. Nursing attitudes toward reporting the type of medication errors, as well as the number reported before and after coaching, education and leadership support are provided. Data was obtained via employee engagement survey questions administered in 2015, and then again in the summer of 2017.
Setting: The project site involves three EDs of a health network in Southeastern North Carolina. The main facility is a 647-bed acute care hospital and regional Trauma Center serving a seven-county area near the coast, the other two facilities include a 80 bed orthopedic hospital and a 12 bed standalone ED.
Participants/Subjects: Potential project participants are 133 Emergency Nurses working in any one of the three network EDs. All participants will be adults 18 years of age or older including all genders and ethnicities. Participants to be included consist of ED nurses that have worked in at least one of the three departments for at least 120 days before the implementation of the project.
Methods: An educational program was developed and administered to the nursing and paramedic staff at each of the project site EDs. A blended approach consisting of face to face and online learning was used. Concepts that were covered in the program included recognition of medication errors and adverse drug events, practices that contribute to medication errors including interruptions during administration, and failure to utilize the existing medication barcode system which studies have shown decreases the number of administration errors (Agency for Healthcare Research and Quality [AHRQ], 2015).
Results/Outcomes: Results of the implementation were mixed, and although some improvements were made, the education, observation and clinical coaching did not have the impact that was anticipated at the beginning of the project. A lack of staff engagement, as noted by participation percentages may have influenced the results. It is important to note that during the time of implementation, two of the three EDs were experiencing record high census and increased hours of inpatient boarding at all three campuses, stretching the abilities of staff to participate in projects. The increased census, combined with continued demands to accommodate all patients quickly and safely, further validated the need for this practice change project to be implemented as previously discussed by Affleck, Parks, Drummond, Rowe, and Ovens (2013).
Implications: This evidence-based project raised awareness and demonstrated that there were opportunities to improve the recognition and reporting of medication errors that occur not only in the ED, but elsewhere in the targeted organization. Increased focus on the need for further development of a culture of safety.