Imrovement Plan Toolkit - Ryan Finn

Improvement Plan Toolkit - Reducing Medication Administration Errors

 

Annotated Bibliography

Best Practices of Medication Administration

Beyea, S. C. (2022). Best practices for safe medication administration: The Official Voice of Perioperative Nursing. AORN Journal, 81(4), 895-8. https://library.capella.edu/login?url=https://www.proquest.com/scholarly-journals/best-practices-safe-medication-administration/docview/200805810/se-2 This article explains the importance of using best practices for safe medication administration of perioperative nurses. The article provides instructions for where to find current evidence-based best practices of medication administration. Additionally, the article discusses the nurses role in preventing MAE’s. The registered nurse can utilize this source to determine best practice of administering oral medications. Understanding best practice of medication administration is a necessary foundation to implementing BCMA technology.

Lenz, J. , Degnan, D. , Hertig, J. & Stevenson, J. (2020). A Review of Best Practices for Intravenous Push Medication Administration. Journal of Infusion Nursing, 40 (6), 354-358. doi: 10.1097/NAN.0000000000000247. This article discusses guidelines associated with administering intravenous medications. Furthermore, this article details strategies to improve patient safety. Registered Nurses can reference this resource to identify evidence-based strategies in administering intravenous medications. Furthermore, the nurse can utilize this source to identify trends in best practice of administering intravenous drugs. Understanding best practice of medication administration is a necessary foundation to implementing BCMA technology.

Wright, K. & Bonser, M. (2020). The Essential Steps of Medication Administration Practices Project medication administration improvement practices among acute inpatients in a tertiary hospital: a best practice implementation project. JBI Evidence Implementation, 18 (4), 408-419. doi: 10.1097/XEB.0000000000000236. MAE’s are highly reported within healthcare systems. This article describes best practice strategies of medication administration. The Five Rights of Medication Administration include the Right Patient, Drug, Dose, Time, and Route. This study used the Acceptance and Commitment Matrix to evaluate data and provide strategies to decrease MAE’s going forward. Nurses act as frontline workers in relation to medication administration and their involvement is crucial in tailoring best-practices of medication administration. This resource can be used to identify the current best practices associated with medication administration. Understanding best practice of medication administration is a necessary foundation to implementing BCMA technology.

.Factors Leading to Medication Administration Errors

Basil, J. H., Premakumar, C. M., Ali, A. M., Tahir, N. A. M., & Shah, N. M. (2022). Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta‑Analysis: An International Journal of Medical Toxicology and Drug Experience. Drug Safety, 45(12), 1457-1476. https://doi.org/10.1007/s40264-022-01236-6 This study reviews critically appraised evidence of the prevalence, causes, and severity of MAE’s within Neonatal Intensive Care Units. The study performed a systemic review through meta-analysis using the random-effects model and the Reason’s Model. The study found that factors contributing to MAE’s are multifactorial with environmental factors having the greatest impact. The registered nurse can utilize this resource as an insight into types of environmental factors that impact the rate of MAE’s. This resource is important to the safety plan as part one of the plan is completing an audit regarding MAE’s.

Jessurun, J. (2022, January 23). Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study. Wiley Online Library. https://doi-org.library.capella.edu/10.1111/jocn.16215 The purpose of this article is to identify the prevalence and factors associated with MAE’s. The article reviewed data about the number of MAE’s and reasons for the MAE’s from two Dutch hospitals. This study found the prevalence of MAE’s to be 13.7 percent. The article found the following factors contribute to MAE’s: "pharmaceutical form; medication class, hospital type, clinical ward type, day of the week, time window, patient-to-nurse ratio interruptions, double check of parenteral medication administration, nursing staff age, gender, educational level, degree type and employment type" (Jessurun 2022). The registered nurse can utilize this source to determine common environmental and personal factors associated with MAE’s. This resource is important to the safety plan as part one of the plan is completing an audit regarding MAE’s.

Liqing Yue, B., Peng, H., Chen, X., Peng, B., Zhang, T., & Zou, W. (2024, October 9). Analysis of the Incidence and Factors Influencing Medication Administration Errors Among Nurses: A Retrospective Study. Wiley Online Library. https://doi-org.library.capella.edu/10.1111/jocn.17483 This article reviewed 343 reported incidences of medication administration errors in China and explored the contributing factors. The study demonstrated that failure to follow procedures correctly and violation of the nurse work system as the primary factors affecting medication administration errors. Furthermore, the study demonstrated personal factors including physical state of the nurse, and lack of medication knowledge of other main factors contributing to medication administration errors. Furthermore, the study indicated that inadequate supervision of patients taking oral medications resulted in missed medications and incorrect time of administration of prescribed medications. The study also displayed how environmental factors including equipment, noisy environments, and interruption of care significantly. The registered nurse can utilize this resource to determine factors that lead to medication administration errors and relate this information to their facility. Phase one of the plan is completing an audit of medication administration errors including preventable factors that lead to them.

Prevention of Nurse Deviation from Best Practices of Medication Administration

Brown, T. , Roberts, E. , Lizarondo, L. , McArthur, A. , Basnet, P. , Basukoski, M. , Cheng, S. , Findlay, B. , Gao, J. , Joshua, R. , Jun, R. , Kennedy, R. , Laing, M. , Lawler, M. , Ling, R. , Lo, Y. , Lockwood, C. , Mandla, A. , Milnes, C. , Rule, M. , Taylor, J. & Thornton, A. (2024). Improving the quality of medication administration practices in a tertiary Australian hospital: a best practice implementation project. JBI Evidence Implementation, 22 (4), 356-370. doi: 10.1097/XEB.0000000000000446. This article explores strategies to prevent deviation of nursing staff from best practice recommendations associated with medication administration. This article implemented a project aimed at emphasizing the importance of completing second checks to prevent deviation from the Five Rights of Medication Administration. Nurses can reference this resource when determining personal strategies to prevent MAE’s.

Ekkens, C. & Gordon, P. (2021). The Mindful Path to Nursing Accuracy. Holistic Nursing Practice, 35 (3), 115-122. doi: 10.1097/HNP.0000000000000440. This article explores a study on the effect of mindfulness training in preventing nurse deviation from best practices of medication administration. This quantitative, experimental study focuses on the Dossey Integral Theory and its impact on cognition. The Dossey Integral Theory integrates physical, mental, emotional, and spiritual needs of patients to nursing practice. The results of the study show a decrease of 73.3% of medication errors after implementation of training on mindfulness. The registered nurse can utilize this resource to identify personal strategies to increase mindfulness. Implementing BCMA technology entails applying a “scan first” approach to medication administration. This resource can aid the nurse in gaining greater insight into mindfulness strategies, which will be used during implementation of the safety improvement plan.

Smith, J. & Upchurch, L. (9900). Nurses’ use of the five rights of medication administration in a comprehensive care unit: a best practice implementation project. JBI Evidence Implementation, Publish Ahead of Print , doi: 10.1097/XEB.0000000000000492. This study looks at strategies to increase compliance with the Five Rights of Medication Administration in an acute care hospital setting. The study found that staff education and visual reminders improved adherence to the Five Rights of Medication Administration. This article provides evidence-based strategies to decrease the prevalence of MAE’s in a healthcare setting. The registered nurse can reference this study for specific strategies and implementation of those strategies into their organization.

Using BCMA Technology to Decrease Medication Administration Errors

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 demonstrates that utilization of bar codes during medication administration has decreased the rate of medication administration errors by 74.2%. The article details the process of using bar-coding systems and how the system ensures utilization of the Five Rights of Medication Administration and allows users to complete medication reconciliation at the bedside. The registered nurse can use this source to reference the clinical significance of using BCMA technology. This source will be beneficial to the safety improvement plan by providing evidence-based research to support the plan.

Sloss, E. & Jones, T. (2020). Alert Types and Frequencies During Bar Code–Assisted Medication Administration. Journal of Nursing Care Quality, 35 (3), 265-269. doi: 10.1097/NCQ.0000000000000446. This article details the different alerts within BCMA technology which include patient mismatches, wrong medications, wrong doses, among others. The article also describes the process of auditing frequency of alerts, which is very applicable to the proposed safety improvement plan. The registered nurse can utilize this source to identify the meaning of different alerts. Understanding how to use BCMA technology will increase the clinical competence of the nurse by aiding in decision making.

Sloss, E. & Jones, T. (2021). Nurse Cognition, Decision Support, and Barcode Medication Administration. CIN: Computers, Informatics, Nursing, 39 (12), 851-857. doi: 10.1097/CIN.0000000000000724 This article uses a conceptual model to explain proper cognition required to utilize BCMA technology. Maintaining proper cognition allows nurses to use BCMA to support clinical decisions during the delivery of care. Furthermore, this article details the individual and environmental factors that influence a nurse’s cognition and decision making. The registered nurse can use it as an overview of BCMA technology and how it fits into the medication administration process. This article will benefit the safety improvement plan by empowering nurses to understand BCMA technology and the implications it has on their job.

 

References

Basil, J. H., Premakumar, C. M., Ali, A. M., Tahir, N. A. M., & Shah, N. M. (2022). Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta‑Analysis: An International Journal of Medical Toxicology and Drug Experience. Drug Safety, 45(12), 1457-1476. https://doi.org/10.1007/s40264-022-01236-6

Beyea, S. C. (2022). Best practices for safe medication administration: The Official Voice of Perioperative Nursing. AORN Journal, 81(4), 895-8. https://library.capella.edu/login?url=https://www.proquest.com/scholarly-journals/best-practices-safe-medication-administration/docview/200805810/se-2

Brown, T. , Roberts, E. , Lizarondo, L. , McArthur, A. , Basnet, P. , Basukoski, M. , Cheng, S. , Findlay, B. , Gao, J. , Joshua, R. , Jun, R. , Kennedy, R. , Laing, M. , Lawler, M. , Ling, R. , Lo, Y. , Lockwood, C. , Mandla, A. , Milnes, C. , Rule, M. , Taylor, J. & Thornton, A. (2024). Improving the quality of medication administration practices in a tertiary Australian hospital: a best practice implementation project. JBI Evidence Implementation, 22 (4), 356-370. doi: 10.1097/XEB.0000000000000446.

Ekkens, C. & Gordon, P. (2021). The Mindful Path to Nursing Accuracy. Holistic Nursing Practice, 35 (3), 115-122. doi: 10.1097/HNP.0000000000000440.

Jessurun, J. (2022, January 23). Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study. Wiley Online Library. https://doi-org.library.capella.edu/10.1111/jocn.16215

Lenz, J. , Degnan, D. , Hertig, J. & Stevenson, J. (2020). A Review of Best Practices for Intravenous Push Medication Administration. Journal of Infusion Nursing, 40 (6), 354-358. doi: 10.1097/NAN.0000000000000247.

Liqing Yue, B., Peng, H., Chen, X., Peng, B., Zhang, T., & Zou, W. (2024, October 9). Analysis of the Incidence and Factors Influencing Medication Administration Errors Among Nurses: A Retrospective Study. Wiley Online Library. https://doi-org.library.capella.edu/10.1111/jocn.17483

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

Sloss, E. & Jones, T. (2020). Alert Types and Frequencies During Bar Code–Assisted Medication Administration. Journal of Nursing Care Quality, 35 (3), 265-269. doi: 10.1097/NCQ.0000000000000446.

Sloss, E. & Jones, T. (2021). Nurse Cognition, Decision Support, and Barcode Medication Administration. CIN: Computers, Informatics, Nursing, 39 (12), 851-857. doi: 10.1097/CIN.0000000000000724

Smith, J. & Upchurch, L. (9900). Nurses’ use of the five rights of medication administration in a comprehensive care unit: a best practice implementation project. JBI Evidence Implementation, Publish Ahead of Print , doi: 10.1097/XEB.0000000000000492.

Wright, K. & Bonser, M. (2020). The Essential Steps of Medication Administration Practices Project medication administration improvement practices among acute inpatients in a tertiary hospital: a best practice implementation project. JBI Evidence Implementation, 18 (4), 408-419. doi: 10.1097/XEB.0000000000000236.