The PICOT question proposed the intervention of a communication tool to prevent medication errors in a pediatric emergency department setting. “Approximately 70 to 80% of health care errors are due to poor team communication and understanding and high-risk environments such as the trauma settings are where the majority of these errors occur” (Courtenay, 2013). This intervention is applicable to any pediatric emergency setting, however for implementing the Children’s Hospital of Wisconsin was chosen.
Outcomes
The expected outcomes of the intervention is to have a reduction in medication errors in the emergency department. An effective handoff communication tool in an emergency room setting is important. The handoff communication tool directly
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This can be accomplished by presenting a PowerPoint during a staff in-service. At the in-service questions and feedback can be taken from nursing staff to assess for any barriers. Some barriers can include nursing attitude, time constraints and documentation. To address such barriers, staff can be educated on the importance of patient centered care. Nursing staff can also develop self-awareness, reflect on biases, values and beliefs that could affect the ability to effectively communicate.
A demonstration of the handoff can be done during the first week of implementation during shift huddles to assess for time barriers in clinical practice. The electronic health record can be audited to gather information. During each nursing handoff documentation, the record can be assessed for trends. The assumption is made that the nursing staff has accurately performed and charted the handoff. Refer to Appendix B for staff in-service flyer.
Conceptual Change
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(2012). Medication Errors in Pediatric Emergencies: A Systematic Analysis. Deutsches Ärzteblatt International, 109(38), 609–616. http://doi.org/10.3238/arztebl.2012.0609
Keebler, J. R., Lazzara, E. H., Patzer, B. S., Palmer, E. M., Plummer, J. P., Smith, D. C., . . . Riss, R. (2016). Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes. Human Factors: The Journal of the Human Factors and Ergonomics Society, 58(8), 1187-1205. doi:10.1177/0018720816672309
Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: A systematic review of quantitative and qualitative evidence. Drug Safety, 36(11), 1045-67. Retrieved from http://search.proquest.com.cuw.ezproxy.switchinc.org/docview/1471055459?accountid=10249
Melnyk, B., & Fineout-Overholt, E. (2015). Asking Compelling, Clinical questions In Evidence-Based Practice in Nursing and Healthcare (3rd ed., p. 27, 283,284).Wolters Kluwer Health.
Neuspiel. D. & Taylor, M. (2013). Reducing the risk of harm from medication errors in children. Health Service Insights pg. 47-59 doi: 10.4137/HSI.S10454. eCollection
In conclusion the study showed a decrease in reported medication errors by 20% (Truitt et al. (2016). The introduction of these systems has greatly changed the delivery of medication in hospitals. Medication administration errors in hospitals put the patient in danger and cause great harm, depending on the severity. It is so important that medication errors do not happen in the hospital. It may not be possible to eliminate all errors, but reducing the amount of errors would benefit
Medication errors in children alone are alarming, but throw an ambulatory care setting into the mix and it spells disaster. When it comes to children and medication in the ambulatory care setting, the dosage range is drastically out of range compared to those that are treated in the hospital setting (Hoyle, J., Davis, A., Putman, K., Trytko, J., Fales, W. , 2011). Children are at a greater risk for dosage errors because each medication has to be calculated individually, and this can lead to more human error. The errors that are occurring are due to lack of training, dosage calculation errors, and lack of safety systems. Medication errors in children who are receiving ambulatory care can avoided by ensuring correct dosage calculation, more in-depth training of personal and safety systems in place.
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly graduated and experienced nurses. International Journal Of Nursing Practice, 18(4), 317-324. doi:10.1111/j.1440-172X.2012.02052.x
The most common kind of medication error is administering the wrong medication or giving wrong doses. A medication error is any error that happens to patients whether they suffer any harmful results or not. Inappropriate nurses-to-patients ratio should be taken into consideration because it can cause medication errors. A new study shows that every year about 210,000-400,000 people who were admitted to the hospital die due to medication error; it also shows that is is “the third leading cause of death behind heart disease and cancer”(MacDonald). For instance, an interview was done with Nurse Carol, a retired nurse; she said that she made a medication error while administering medication to one of her patients. She said that she was rushing and accidentally gave Cozaar to one of her patients instead of Colace. Cozaar is often used for high blood pressure and Colace is for constipation. She said her patient’s pressure dropped very low after taking the medication; she realized then that she gave the patient the wrong medication. Nurse Carol also said that if she did no...
In the nursing profession, communication is a tool to be used effectively in shift-to-shift report to ensure continuity of care and patient safety (Matic, Davidson, & Salamonson, 2010, p. 184). Benson, Rippin-Sisler, Jabusch, and Keast (2007) explain “for a report to be meaningful, the information passed along to the receiver must be done in a way that is effective and efficient; otherwise, the point of communicating the information may be lost” (p. 80). The Joint Commission (TJC) defines barriers in communication as a leading threat to patient safety (Matic et al., 2010, p. 185). Patient safety and continuity of care can be maintained by implementing a handoff communication tool and bedside nurse-to-nurse handoff.
stationed staff in one area of a hospital ED to treat patients presenting to the ED" (Minott, 2008). This results of this experiment stated that "28 percent of patients diverted back home and avoided hospital readmission" (Minott, 2008). Another study showed that "greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital related death" (Kane, Shamiliyan, Mueller, Duval and Wilt, 2007). This shows that there is a correlation between direct care between healthcare providers and a better outcome amongst patients.
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
The purpose of this paper is to show most of medication errors occur on the night shifts and the weekend shifts in pediatric care, Bar Code Medication Administration System’s success on extremely low medication errors in pediatric care, and tenfold medication errors in pediatric care.
Agyemang, REO, and A While. "Medication errors: types, causes and impact on nursing practice." British Journal of Nursing (BJN) 19.6 (2010): 380-385. CINAHL Plus with Full Text. EBSCO. Web. 7 Mar. 2011.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
For many patients the scariest part of being in the hospital is having to rely on other people to control their life changing decisions. There are multiple causes of patient harm, one of the major contributors are medication errors made by health care professional. Medication errors are inappropriate dispensing and administration of drugs which cause harmful effects such liver damage and excessive bleeding. Most cases of medication errors in hospitals occur as a result of wrong diagnosis by the doctors leading administration of inappropriate drug, poor communication between doctors and nurses and between patients and nurses who issue the drugs. However in an article by the International Journal of Nursing practice, in Australia many occurrences
Tzeng, H., Yin, C., & Schneider, T. E. (2013). Medication Error-Related Issues In Nursing Practice. MEDSURG Nursing, 22(1), 13-50.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
Bedside Shift Report to Address Handoff Communication Errors Communication is a vital component of safe, quality health care that takes place between doctors, nurses, patients, and families. The sharing of patient information is especially important during times of patient transfer, patient discharge, and health care provider shift change. Handoff can be defined as the transfer of information, primary responsibility, and authority from one exiting caregiver to another oncoming caregiver (Friesen et al.). The purpose of handoff is to relay essential patient information, promote continuity of care, assure the safe transfer of care of the patient to a qualified and competent nurse, provide patient education, debrief the oncoming staff, plan and
Patient and/or their family members can voice any questions or concerns they may have with the nurses. With reports given at the bedside in the presence of the patient and family, they will know what to expect regarding their plan of care. When patients feel safe, patient satisfaction with the hospital will increase.