Patient Safety: Improving Medication Reconciliation Accuracy for Long-Term Care Residents by Annisa L. Stover MSN, Southern University, 2008 BSN, Our Lady of the Lake College, 2005 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2016 During transition of care, inaccurate medication reconciliation is associated with increased risk of adverse events for patients. Older adults are the population most often affected by medication errors, and long-term care facilities struggle to accurately document medication reconciliation. Errors are more common at hospital discharge, but the critical moment for detecting and resolving them is during hospital or long-term care admission. Guided by Rosswurm and Larrabee's model for change, Rogers' diffusion of innovation, and the Multi-Center Medication Reconciliation Quality Improvement toolkit, a 6-member interdisciplinary team composed of nurses, pharmacists, and institutional stakeholders was mobilized to develop policy and practice guidelines as well as secondary documentation necessary to implement and evaluate a quality improvement initiative to address medication reconciliation. Current evidence was explored and used to develop policy and practice guidelines for medication reconciliation, then submitted to 4 scholars, including 2 practice experts, a nurse administrator, and a specialist in pharmacy, to validate content. Scholarly validation supported the premise that the developed products would be beneficial in the accurate documentation of medication reconciliation. Scholarly feedback was evaluated by comparing to current best practices for medication reconciliation. Implementation, education, and evaluation plans were developed to guide operationalization of policy and practice guidelines. This project may positively affect social change by fostering a new practice policy, practice guidelines, and supporting documents to manage medication reconciliation of long-term care residents transitioning to acute care settings, thereby improving medication safety at transitions of care for vulnerable populations.

Class of 2010 Abstract / OBJECTIVES: The purpose of the study was to determine the knowledge of third year pharmacy students about the safety of certain medications during pregnancy and to assess their awareness of an important resource available on medication safety. METHODS: The study used an analytical cross-­‐sectional design. A pre-­‐test was administered to determine baseline knowledge. Dee Quinn provided a presentation on teratogens. The same test was then administered as a post-­‐test to assess the amount of knowledge gained from the presentation. The pre and post-­‐tests were matched for data analysis. A mean and standard deviation were developed for pre and post-­‐test data and the results were compared to each other using a t-­‐test for dependent groups. RESULTS: Students showed a significant increase in knowledge after the presentation (p<0.0001). 78% of students had improved scores after the presentation. 100% of students felt that pharmacists could help make a difference in preventing malformations due to teratogen exposure. There was no significant difference between men and women or students with children and without children. Work experience did not affect knowledge scores. 64% of students felt more comfortable counseling pregnant patients after the presentation. Awareness of the Teratology Information Service improved after the presentation. CONCLUSIONS: After the presentation, students rated themselves as more comfortable speaking with pregnant patients and showed improved knowledge of teratogens. Gender, being a parent and work experience had no relevance on knowledge scores. The investigators recommend that this presentation be given to all students at the College of Pharmacy to improve knowledge in this area.

Medication safety is a key contribution to patient safety in health care settings. Health care researchers and scholars frequently report and discuss nurses medication administration practices or medication errors associated with patients safety in hospitals. Yet there are gaps in published reports about how practitioners view the larger phenomenon of medication safety as it unfolds on a hospital unit. Research is needed to advance our understanding of medication safety as it comes together amidst the interrelated elements in a complex hospital environment, and what practitioners identify and associate with medication safety in this context. In this study, medication safety was explored with participants from nursing and pharmacy departments on one Canadian hospital unit. Using a restorative theoretical approach and citizen science methodology, the researcher engaged in critical conversations with practitioner and decision-maker participants (n=68) to explore elements that support and those that present barriers to medication safety through focus groups, photo walkabouts, on-unit observations, and photo elicitation. Themes from the data revealed that (1) unit structures shape medication safety, (2) medication system design affects medication safety, (3) practitioners embed accountability for medication safety into their practice and processes, (4) unit culture influences medication safety, (5) practitioners devise and employ workarounds to circumvent ongoing barriers to medication safety, and (6) participants envisioned, and in some cases implemented, restorations to improve medication safety on their unit. Findings highlight a range of contextual, interrelated supports for and barriers to medication safety that participants discovered and shared knowledge about on their unit. Participants envisioned medication safety improvements that could be implemented at present and in the future. Workarounds, power, and possibilities for medication safety improvements related to current medication system design in health care systems are discussed.

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Objective: Medicine administration is the last process of the medication cycle. However, errors can happen during this process. Children are at an increased risk from these errors. This has been extensively investigated but evidence is lacking on effective interventions. Therefore, the aim of this research is to propose safety measures to reduce medication administration errors (MAE) in the Paediatric Intensive Care Unit (PICU). Method: The research was carried out over five studies; 1) systematic literature review, 2) national survey of PICU medication error interventions, 3) retrospective analysis of medication error incidents, 4) prospective observation of the administration practice, and 5) survey of PICU healthcare professionals' opinions on MAE contributory factors and safety measures. Results: Hospital MAE in children found in literature accounted for a mean of 50% of all reported medication error reports (n= 12552). It was also identified in a mean of 29% of doses observed (n= 8894). This study found MAE retrospectively in 43% of all medication incidents (n= 412). Additionally, a total of 269 MAEs were observed (32% per dose observation). The characteristics of the interventions used to reduce MAE are diverse but it illustrated that a single approach is not enough. Also for an intervention to be a success it is fundamental to build a safety culture. This is achieved by developing a culture of collaborative learning from errors without assigning blame. Furthermore, MAE contributing factors were found to include; interruptions, inadequate resources, working conditions and no pre-prepared infusions. The following safety measures were proposed to reduce MAE; 1) dose banding, 2) improved lighting conditions, 3) decision support tool with calculation aid, 4) use of pre-prepared infusions, 5) enhance the double-checking process, 6) medicine administration checklist, and 7) an intolerant culture to interruption. Conclusion: This is one of the first comprehensive study of to explore MAE in PICU from different perspectives. The aim and objectives of the research were fulfilled. Future research includes the need to implement the proposed safety measures and evaluate them in practice.

Medication errors are one of the most common causes of patient injuries in healthcare systems. Poor labelling has been identified as a contributing factor of medication errors, particularly for those involving injectable drugs. Colour coding and colour differentiation are two major techniques being used on labels to aid drug identification. However, neither approach has been scientifically proven to minimize the occurrence of or harm from medication errors. This thesis investigates potential effects of different approaches for using colour on standardized labels on the task of identifying a specific drug from a storage area via a controlled experiment involving human users. Three different ways of using colour were compared: labels where only black, white and grey are used; labels where a unique colour scheme adopted from an existing manufacturer’s label is applied to each drug; colour coded labels based on the product’s strength level within the product line. The results show that people might be vulnerable to confusion from drugs that have look-alike labels and also have look-alike, sound-alike drug names. In particular, when each drug label had a fairly unique colour scheme, participants were more prone to misperceive the look-alike, sound-alike drug name as the correct drug name than when no colour was used or when colour was used on the labels with no apparent one-to-one association between the label colour and the drug identity. This result could suggest a perceptual bias to perceive stimuli as the expected stimuli especially when the task involved is familiar and the stimuli look similar to the expected stimuli. Moreover, the results suggest a potential problem that may arise from standardizing existing labels if careful consideration is not given to the effects of reduced visual variations among the labels of different products on how the colours of the labels are perceived and used for drug identification. The thesis concludes with recommendations for improving the existing standard for labelling of injectable drug containers and for avoiding medication errors due to labelling and packaging in general.

Medication errors are one of the most common causes of patient injuries in healthcare systems. Poor labelling has been identified as a contributing factor of medication errors, particularly for those involving injectable drugs. Colour coding and colour differentiation are two major techniques being used on labels to aid drug identification. However, neither approach has been scientifically proven to minimize the occurrence of or harm from medication errors. This thesis investigates potential effects of different approaches for using colour on standardized labels on the task of identifying a specific drug from a storage area via a controlled experiment involving human users. Three different ways of using colour were compared: labels where only black, white and grey are used; labels where a unique colour scheme adopted from an existing manufacturer’s label is applied to each drug; colour coded labels based on the product’s strength level within the product line. The results show that people might be vulnerable to confusion from drugs that have look-alike labels and also have look-alike, sound-alike drug names. In particular, when each drug label had a fairly unique colour scheme, participants were more prone to misperceive the look-alike, sound-alike drug name as the correct drug name than when no colour was used or when colour was used on the labels with no apparent one-to-one association between the label colour and the drug identity. This result could suggest a perceptual bias to perceive stimuli as the expected stimuli especially when the task involved is familiar and the stimuli look similar to the expected stimuli. Moreover, the results suggest a potential problem that may arise from standardizing existing labels if careful consideration is not given to the effects of reduced visual variations among the labels of different products on how the colours of the labels are perceived and used for drug identification. The thesis concludes with recommendations for improving the existing standard for labelling of injectable drug containers and for avoiding medication errors due to labelling and packaging in general.

No description available.

Yes / Conference abstract from the British Geriatrics Society Autumn Meeting, 14-16 Nov 2018, London, UK.