| Wednesday, July 13, 2005: 10:00 AM-11:30 AM | |||
| Keeping Patients Safe From Medication Errors | |||
| Learning Objective #1: Explain how data analysis and trending of root causes of medication errors can impact patient safety | |||
| Learning Objective #2: Identify transdisciplinary best practices and process improvements to decrease medication errors | |||
| As a progressive growing community hospital with 1600 employees, our goal is to keep patients safe by using evidence based research to improve practice. Executive Leadership challenged a nursing and pharmacy leader to attack medication errors and create a culture that would embrace the need for change through a transdisciplinary team. This team included representatives from nursing, pharmacy, respiratory, imaging services, education, and information services. Information was collected through surveying staff, interviewing physicians, and observing medication dispensing/delivery process. The first milestone was to foster a “no blame” culture that encouraged error reporting to improve practice. This was accomplished through proactive leadership and easing the burden through reporting errors online or via telephone. Medication error reporting cultural shift lead to the Medication Error Review Team (Physician, Patient Safety-Officer, co-chairs) who monthly assigns a severity score to each medication event and trends precipitating factors. These trends are reported to staff and executives. For six months the number one trend was transcription errors. In response, the transdisciplinary team developed a plan. Initially, communication occurred to reinforce accuracy and review of policies. The innovative and comprehensive solution was a computer generated Medication Administration Record (MAR). Using the current tracking/charging system, the team developed evidence-based practices for medication administration including standardizing administration times on a computer generated MAR thus eliminating several steps in our process, most importantly secretarial transcription. After the development phase, education and implementation were successfully completed in seven weeks. In one month, the transcription errors went from 30% to less than 1%. | |||
| Organizer: | Holly L. Lorenz, RN, MSN | ||
| Authors: | Jill Marie Larkin, RN, MSN, MBA Cheryl V. Dodson, RN, MBA Janet Darlene Lindner, RPh | ||