medication safety improvement plan toolkit

Designated Medication Preparation Areas to Reduce Medication Errors

Bucknall, T., Fossum, M., Hutchinson, A. M., Botti, M., Considine, J., Dunning, T., Hughes, L., Weir‐Phyland, J., Digby, R., & Manias, E. (2019). Nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in an acute hospital setting. Journal of Advanced Nursing, 75(6), 1316–1327. https://doi.org/10.1111/jan.13963

This article serves as an example of how nurses operate in dynamic, complex adaptive systems. To increase      patient safety and lower medication administration errors, one must recognize and comprehend the mental effort and complicated interconnections. Interruptions and distractions should be key consideration when developing interventions to avoid medication mistakes in hospital settings since nurses regard them as substantial hazards to the delivery of medications in hospitals. Medication errors rise as a result of workflow disruptions during medication administration procedures. In order to reduce interruptions and medication errors, intervention design may benefit from an understanding of how nurses make practice decisions and perceive medication administration procedures. Managers should attempt to comprehend the complicated workflow factors that nurses face when administering medications in hospital settings when designing policies for medication administration. Developing and evaluating strategies to lessen the mental load and prevent interruptions and diversions while administering medications should be the main focus of future research. Drug administration workflow disruptions have been linked to an increase in medication mistakes. Healthcare organizations have looked at various models, such as “sterile cockpits” to prevent distractions during crucial tasks in order to lessen the risks of medication error caused to interruptions. By adopting a focused medication procedure, staff education, and visible reminders (vests, signs, medication preparation room) to other staff members and patients to avoid causing distractions during medicine administration, the sterile cockpit approach is applied to reduce disruptions. This article also explores the benefit of utilizing mindfulness techniques to become situationally aware, lowering the likelihood of mistakes. This resource could be beneficial for nurses as it brings awareness to the frequent interruptions and distractions that nurses experience in their day-to-day workflow. It emphasizes the importance of being self-aware of these identified factors and their contribution to medication administration errors. This resource could empower nurses to work with their leaders to develop personal improvement strategies and organizational processes that could help decrease the rate of medication administration errors. 

Huckels-Baumgart, S., Baumgart, A., Buschmann, U., Schüpfer, G., & Manser, T. (2021). Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: A prospective observational study. Journal of Patient Safety, 17(3), e161–e168. https://doi.org/10.1097/pts.0000000000000335

The numerous work interruptions nurses have at work are discussed in this article. These frequent interruptions at    work are typically started by coworkers. There is minimal evidence to suggest reducing interruptions during drug preparation, despite the fact that they are frequent and have previously been identified as a significant factor in medication administration problems. The study presented in this article demonstrates the beneficial effects of a hospital-based intervention; following the establishment of distinct medication rooms, the rates of interruption and medication error considerably decreased. Although "no interruption zones," separate medicine rooms, and safety vests help create a better working environment for preparing prescriptions, nurses also need to feel confident enough to speak up for themselves to prevent interruptions and conversation while doing so. They will be more successful if work design is properly utilized to assist these efforts. This resource aids nurses in understanding the importance that the reduction of interruptions and disruptions has in reducing medication administration errors. Nurses should utilize this resource to educate themselves on the importance of speaking up for safety, particularly during medication preparation and administration.

Savva, G., Papastavrou, E., Charalambous, A., Vryonides, S., & Merkouris, A. (2022). Exploring nurses’ perceptions of medication error risk factors: Findings from a sequential qualitative study. Global Qualitative Nursing Research, 9, 233339362210948. https://doi.org/10.1177/23333936221094857

This article gives readers a behind-the-scenes look at how various nurses perceive the causes of medication administration errors. These perceptions are consistent with the reality that medication errors are a multifaceted problem that necessitates concerted efforts to reduce and eliminate the likelihood of putting patients at risk. Error-causing factors have their origins in the working environment, particularly with regard to interruptions and distractions during the preparation of medications, as well as in the characteristics of the medications, employees, and patients participating in the medication process. A detailed understanding of the underlying factors contributing to the problem must be established in order to develop tailored interventions to address the medication administration error issue in hospitals. In order to effectively address medication administration error factors, it is crucial to take into account nurses' perceptions. This resource can be utilized by nurses to educate themselves on the multifactorial causes of medication administration errors. The nurse could use the information obtained from this resource to identify factors in his/her own organization and collaborate with leaders to develop organizational improvements to reduce medication errors. 

Utilization of the Five Rights Method during Medication Administration

Alomari, A., Sheppard‐Law, S., Lewis, J., & Wilson, V. (2020). Effectiveness of clinical nurses’ interventions in reducing medication errors in a paediatric ward. Journal of Clinical Nursing, 29(17-18), 3403–3413. https://doi.org/10.1111/jocn.15374

     This article focuses on evaluating multiple interventions to reduce medication errors. These particular interventions

were developed and implemented by nurses to reduce the rate of medication errors and to improve nurses’   medication administration practice. This particular article sheds light on the importance of actively involving nurses in the development of solutions, as they are considered a key stakeholders in the medication administration process. The five-right method is recommended as the fundamental guideline for safe medication administration in the article. It has been shown to significantly lower the rate of medication errors when used in conjunction with technology and knowledge of how human error and dosage affect medication administration outcomes. This is a beneficial informational resource for nurses that educates them on the critical role they play in reducing medication administration errors. Nurses can refer to this resource to assist them in encouraging each other to consistently practice the five rights method of medication administration as a simple and effective intervention to reduce medication administration errors.

Kruse, C., Smith, M., & Clarke, D. (2022). Technology alone does not achieve error reduction - a study of handwritten, tick-sheet, ink stamp and electronic medical prescriptions. South African Journal of Surgery, 60(4), 259–267. https://doi.org/10.17159/2078-5151/sajs3670

The use of current technology and its potential to lower medication errors are examined in this article. In this study, the authors compared handwritten prescriptions against computerized prescriptions throughout the process. According to research, human error reduction solutions fail to have the desired effect of reducing human error if technology is used in isolation from human factors engineering and constant critical analysis. This demonstrates how important it is to follow the fundamental cognitive stages (i.e. the five rights method) when preparing and administering medication, despite the advances in healthcare technology. This resource is beneficial in providing nurses with an understanding of the importance of not solely relying on technology for safe medication administration. Nurses can use this resource to gain a better understanding of how utilizing the five rights method along with bar code scanning helps to reduce medication administration errors.

Mula, C. (2019). The examination of nurses’ adherence to the ‘five rights’ of antibiotic administration and factors influencing their practices: A mixed methods case study at a tertiary hospital, malawi. Malawi Medical Journal, 31(2), 126. https://doi.org/10.4314/mmj.v31i2.4

     This article presented findings from a study that examined the use of antibiotics and the five rights method during

medication administration. The results of this study are in line with a poll of a sample of registered nurses from the Georgia Board of Nursing, in which 78% of the nurses admitted to making one or more mistakes and 77% admitted to not abiding by the "Five Rights" of drug administration. Exhaustion, inexperience, and pace/staffing/patient load were all factors in medication errors. The findings suggest that non-compliance with the "Five Rights" may be widespread and may lead to medication errors. This resource helps to serve as a reminder to nurses of the importance of following the five rights method during medication preparation and administration. Since this resource identifies personal factors that may contribute to medication errors and non-compliance with the five rights method, nurses should use this resource to self-reflect on their own practices during medication administration.

Utilization of Barcode Scanning to Reduce Medication Administration Errors

Ho, J., & Burger, D. (2020). Improving medication safety practice at a community hospital: A focus on bar code medication administration scanning and pain reassessment. BMJ Open Quality, 9(3), e000987. https://doi.org/10.1136/bmjoq-2020-000987

This article discusses the importance of bar code medication administration scanning and the impact that the implementation of this practice has on patient safety and the cost-effectiveness that this process has within organizations. This article also highlights organizational factors that may contribute to noncompliance with barcode scanning and provides strategies to improve compliance among staff. Nurses should utilize this resource to develop an understanding of the benefits of barcode scanning during medication administration and to also educate themselves on the financial impact that barcode scanning has on the organization. Nurses can use this resource to identify organizational barriers and assist leaders in developing strategies to improve compliance with barcode scanning. 

Koyama, A.K., Claire-Sophie, S.M., Li, L., Bucknall, T., & Westbrook, J. I. (2020).Effectiveness of double checking to reduce medication administration errors: a systematic Review. BMJ Quality & Safety, 29(7), 595-603. https://doi.org/10.1136/bmjqs-2019-009552

 In order to prevent medication administration errors, the authors of this study undertook a systematic review analyzing the impact that double-checking medication has on reducing medication administration errors. According to the study's findings, double-checking is a sensible safety measure that has been ingrained in nursing practice for many years. Double-checking was done with two RNs for verification prior to technological breakthroughs like barcode scanning. This study demonstrated how the adoption of barcode-scanning medication administration has frequently eliminated the requirement for two RN verification. Barcode scanning frequently has inconsistencies and workarounds, thus more research is required to understand the implications of using this technology alone for double-checking. This resource can assist nurses in understanding the role that barcode scanning has during medication administration. This resource is also beneficial for nurses to review, as it shows the impact that inconsistency and workarounds have on barcode scanning and medication administration errors. Nurses can use this resource to identify barriers within their organization to compliance with barcode scanning. The identification of these barriers can lead to interdisciplinary collaboration with leaders, IT, and pharmacy to develop organizational improvements to increase compliance with barcode scanning.

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing, 46(6), 884–891. https://doi.org/10.1016/j.jen.2020.07.004

 This article focused on a study in which barcode scanning technology was implemented for use in an emergency department. The study was conducted using direct observation and comparison of medication error rates before and 3 months after implementation. The results of the study showed a reduction in medication error rates after the implementation of barcode medication administration and also showed an improvement in nurse satisfaction. This resource is beneficial in aiding in the understanding of the effectiveness of barcode scanning for medication administration. Nurses should utilize this resource to gain an understanding of the role they play in ensuring the effectiveness of barcode scanning for medication administration.

Importance of Interdisciplinary Collaboration to Achieve Desired Outcomes

Afaya, A., Konlan, K., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07187-5

This article identified and examined organizational barriers that contributed to a lack of nurses reporting medication administration errors. The authors of this article concluded from their review that the type of environment (punitive vs positive) heavily influenced the rate at which medication errors were reported. The authors suggest that in an effort to increase nurse reporting of medication errors, an open feedback system should be implemented, and the system in which the medication error is reported should be effective and non-time consuming. This is a beneficial resource to nurses as it promotes the reporting of medication errors and provides strategies that nurses and leaders can use to effectively work together to improve the success of medication administration error reporting. The nurse should use this resource to provide a comparison of the way in which reporting of medication errors is viewed in their organization. If such reporting is considered to be punitive among staff, the nurse could use this reference to collaborate with leaders within the organization to push for cultural change. 

Ahmad, F., & Huvila, I. (2019). Organizational changes, trust and information sharing: An empirical study. Aslib Journal of Information Management, 71(5), 677–692. https://doi.org/10.1108/ajim-05-2018-0122

  This article shares a study that aims to deepen our understanding of the connections between organizational change and information sharing by demonstrating that if organizational changes are seen favorably, employee and manager trust will rise, which in turn will improve information sharing. The article focuses on the importance of ensuring the practical success of organizational change and highlights the impact that negative perceptions by staff could have on the implementation of organizational change. Negative impressions could result in less information sharing which could lead to detrimental outcomes for organizations and their stakeholders, increasing the likelihood that it won't be effective. This resource is beneficial for helping nurses to understand the process of an organizational change and the role they play in the success of its implementation. Nurses should refer to this resource prior to the implementation of medication process changes.

Hussain, S., Lei, S., Akram, T., Haider, M., Hussain, S., & Ali, M. (2018). Kurt lewin's change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123–127. https://doi.org/10.1016/j.jik.2016.07.002

 This article reviews the impact that following Kurt Lewin’s change theory model has on the success of organizational change. This article also demonstrates the critical importance of actively including employees in change initiatives to improve results and reduce employee resistance or noncompliance. This resource helps nurses gain an understanding of Kurt Lewin’s change theory model and how it is applied to organizational changes within their organization. Nurses should use this resource to educate themselves on the impact they have on organizational change and use this information to empower themselves to become invested and involved in their unit during the medication safety improvement plan implementation.

Russ-Jara, A. L., Luckhurst, C. L., Dismore, R. A., Arthur, K. J., Ifeachor, A. P., Militello, L. G., Glassman, P. A., Zillich, A. J., & Weiner, M. (2021). Care coordination strategies and barriers during medication safety incidents: A qualitative, cognitive task analysis. Journal of General Internal Medicine, 36(8), 2212–2220. 

   https://doi.org/10.1007/s11606- 020-06386-w

This article focuses on the role that pharmacists play in care coordination efforts after a medication error has occurred. The authors of this article conducted a study to identify barriers that exist in care coordination efforts between healthcare professionals and pharmacists. Through their study, it was identified that enhancements to the electronic health record and improved communication efforts between healthcare professionals and pharmacists would increase care coordination. This resource is beneficial to nurses as it highlights the importance of communication and interdisciplinary collaboration when a medication error occurs. The nurse could use this resource to identify ways in which collaborative efforts could be increased in their organization to reduce the rate of medication errors.