Improvement Plan Tool Kit

Introduction

Communication and collaboration in the healthcare sector are indispensable practices that promote relevant information sharing, improve professionals’ knowledge, and contribute to care quality. In this respect, a resource tool kit is a valuable instrument that arms front-line staff with authoritative, helpful resources and allows them to examine specific issues and reveal practical safety interventions. Thus, this paper aims at building a comprehensive toolkit, the purpose of which is to outline resources necessary for issues related to medication administration errors (MAEs). The toolkit will be categorized into four categories: causes and contributing factors, patients’ and nurses’ education and collaboration, clinical and professional strategies, and technological interventions.

Causes and Contributing Factors

Medication errors and adverse drug events. (2019). Patient Safety Network. Web.

The given source directly relates to medication errors and helps nurses be aware of respective definitions, including ADE, highest-risk medication, and potential, ameliorable, and non-preventable ADE. In addition, the webpage provides recent data and statistics connected with these problems, giving an idea of the current situation and the critical importance of complying with related guidelines. Furthermore, healthcare providers can examine indispensable safety strategies at different stages of the medication administration pathway. These recommendations are particularly important since they aid professionals in detecting and preventing sentinel events. They are also helpful while designing improvement plans and in-service courses.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dispensing errors and prevention. StatPearls Publishing.

The article provides the most recent data about medication errors, including mortality, cost, and incidents occurring in the United States. Besides, the article helps professionals and students be profoundly acquainted with the authoritative organizations’ necessary definitions, such as medication error, adverse drug event (ADE), sentinel event, and others. The authors also elaborate on issues and types of MAEs and offer relevant advice for medical providers on how to avert them. In particular, concerning distractions, they highly recommend the appropriate organization of physicians’ and nurses’ workflow. Therefore, the article can be useful due to that it provides a comprehensive picture of MAEs, which can assist in daily medical practice or developing improvement plans or in-service training.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication Administration Errors and Associated Factors Among Nurses. International Journal of General Medicine, 13, 1621. Web.

The given study describes the most widespread causes and factors of MAEs and gives specific recommendations for staff and medical organizations. For example, nurses can discover that the most prevalent mistake is administering medication at the wrong time, which highlights the importance of double-checking. The researchers also specify that poor communication between healthcare providers is the most potent factor. In addition, the source is helpful because the information is directly gathered from the questionnaires of participants working in medical facilities. Overall, personnel can learn about the most widespread errors and put the necessary efforts to prevent them in the future.

Patients’ and Nurses’ Education and Collaboration

Baylor, C., Burns, M., McDonough, K., Mach, H., & Yorkston, K. (2019). Teaching medical students skills for effective communication with patients who have communication disorders. American Journal of Speech-Language Pathology, 28(1), 155-164. Web.

The study profoundly evaluates the influence of training curriculum on medical students’ communicative abilities while interacting with patients who have communication impairments. Hence, this article is beneficial since it encompasses the issues, such as language, speech, cognition, or hearing disorders, that frequently result in MAEs, ADEs, and other safety and care problems. In particular, the researchers offer valuable recommendations for designing training programs that consider communication impairments to reach tangible patient outcomes. Furthermore, students and nurses can gain practical information about multiple effective strategies and tools promoting communication with such patients. Besides, the article can be handy while developing and implementing improvement initiatives.

Hassan, I. (2018). Avoiding medication errors through effective communication in the healthcare environment. Movement, Health & Exercise, 7(1), 113-126. Web.

This article thoroughly explores communication concerns, barriers, and mediums and their relation to medication errors. The author also emphasizes the significance of proper communication practices for patient safety in healthcare settings and proposes respective strategies to avoid MAEs and ADEs. Specifically, Hassan indicates that errors happen because of inadequate information transformation stemming from using medical language, insufficient explanation, or the negligence of details. The article is primarily valuable in that the researcher, along with their colleagues, has extracted and summarised the most appropriate information from articles between 2004 and 2017. Thus, the medical professionals have an excellent opportunity to understand prevalent issues and improve their communication skills in their routine clinical practice, which favorably imprints on patient safety.

Wittenberg, E., Ferrell, B., Kanter, E., & Buller, H. (2018). Health literacy: Exploring nursing challenges to providing support and understanding. Clinical Journal of Oncology Nursing, 22(1), 53-61. Web.

This study examines communication skills among oncology nurses and patient health literacy and highlights the importance of providing health literacy assessment and support. The scholars provide information regarding the most prevailing challenges nurses face and indicate nurses’ mistakes while caring for patients with low health literacy. In particular, the study shows that speaking English as a second language is the most common problem. The authors also give specific examples of low-literacy patients and different incidents related to this problem and deliver strategies. Overall, this article is beneficial because inadequate literacy among patients is also a frequent cause of MAEs, and, hence, nurses should know associated interventions.

Clinical and Professional Strategies

Danovitch, I., Vanle, B., Van Groningen, N., Ishak, W., & Nuckols, T. (2020). Opioid overdose in the hospital setting: A Systematic Review. Journal of Addiction Medicine, 14(1), 39-47. Web.

This systematic review examines the significant issue of opioid overdose in the hospital environment, which is tightly connected with medication errors. The researchers determine the occurrence of opioid overdose events and detect factors related to them. Thus, this study can acquaint medical professionals, especially students, with the hazardous and harmful consequences of overdosing and the most prevalent toxic opioid needing careful attention while prescribing. Furthermore, the study provides some effective interventions that can minimize the risk of overdosing or alleviate the aftermath that occurred after this adverse event. Altogether, the research information can be beneficial to all medical professionals and applied during in-service sessions to make participants familiar with opioid overdose and preventive or mitigating strategies.

Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., Aguilar, V., & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: An observational study of nurses. Journal of Nursing Management, 25(7), 498-507. Web.

The interruptions while administering medication are regarded as the most frequent causes of MAEs and ADEs. This observational study aims at exploring this critical issue and its adverse outcomes. The study also delivers a brief explanation of MAES, main related terms, and facts. For instance, the authors investigated that the most shared source of interruptions is nurse-initiated (40 percent), and the most frequent stage is medication preparation (73 percent). This indicates the necessity for nurses to pay more close attention to medication administration during this phase. Moreover, medical providers can discover different effective practices while implementing improvement initiatives to decrease MAEs.

Nguyen, M. N. R., Mosel, C., & Grzeskowiak, L. E. (2018). Interventions to reduce medication errors in neonatal care: A systematic review. Therapeutic Advances in Drug Safety, 9(2), 123-155. Web.

Neonatal care gains the primary importance in medication administration, requiring heightened consideration and improved efforts. In this regard, the study by Nguyen et al. (2017) presents an estimate of the efficacy of various personnel, organizational, technological, and pharmacy interventions to reduce medication errors in this field of care. The researchers provide factual information, including definitions, roots, and statistics, that help develop an awareness of this issue. The review concludes that these interventions mostly lead to a considerable decrease in MAEs, but there is an acute need for their combination in hospital settings. Overall, the study helps nurses realize the significance of MAEs’ prevention in neonatal care and learn necessary strategies.

Technological Interventions

Computerized provider order entry. (2019). Patient Safety Network. Web.

The present article in-depth describes computerized provider order entry, including its background, benefits, disadvantages, evidence of effectiveness, associate concerns, and the current contexts. For example, CPOE’s advantages include averting problems with specification errors, handwriting, and drug names and interactions, the ability to offer alternative treatments or tests, and integration with electronic medical records and CDSS. Furthermore, the article clearly explains the steps of prescribing and administering medication, including Ordering, Transcribing, Dispensing, and Administration, and links them to the system. This information is immensely useful for all healthcare professionals while working with advanced systems and delivering care for patients. Besides, this webpage can be used for developing the content of training courses for novel staff or students.

Prgomet, M., Li, L., Niazkhani, Z., Georgiou, A., & Westbrook, J. I. (2017). Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: A systematic review and meta-analysis. Journal of the American Medical Informatics Association, 24(2), 413-422. Web.

This systematic review and meta-analysis examined the benefit of CPOE and CDSS for the prevention MAEs and ADEs in intensive care units (ICUs). The scholars provide related definitions and relevant information about these systems and infer that CPOE and CDSS are associated with significant MAEs reduction. Medical professionals can use this study for advocating technological intervention in healthcare facilities, especially in ICUs that are characterized by intense workflow and risks of MAEs. Besides, clinicians and nurses can utilize the review’s information while developing and realizing their safety improvement initiative or plans.

Shah, N., & Jani, Y. (2020). Implementation of smart infusion pumps: A scoping review and case study discussion of the evidence of the role of the pharmacist. Pharmacy, 8(4), 239. Web.

This article targets exploring the principle factors for adopting the smart infusion pumps (SIPs) and presents a case study of constructing and implementing a drug library connected with SIPs. The researchers describe the purposes, benefits, and issues related to SIPs and give an illustrative example of quality drug library creation. Besides, the study discusses necessary elements of training programs that should be considered before using SIPs, which can assist in designing in-service sessions. Although the authors’ recommendations more concern pharmacists, noting that they are primarily responsible for drug libraries, evidently, these specifications can freely be used for healthcare purposes overall. Thus, the information can be helpful when implementing initiatives that contain SIPs.

References

Baylor, C., Burns, M., McDonough, K., Mach, H., & Yorkston, K. (2019). Teaching medical students skills for effective communication with patients who have communication disorders. American Journal of Speech-Language Pathology, 28(1), 155-164. Web.

Computerized provider order entry. (2019). Patient Safety Network. Web.

Danovitch, I., Vanle, B., Van Groningen, N., Ishak, W., & Nuckols, T. (2020). Opioid overdose in the hospital setting: A Systematic Review. Journal of Addiction Medicine, 14(1), 39-47. Web.

Hassan, I. (2018). Avoiding medication errors through effective communication in healthcare environment. Movement, Health & Exercise, 7(1), 113-126. Web.

Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., Aguilar, V., & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: An observational study of nurses. Journal of Nursing Management, 25(7), 498-507. Web.

Medication errors and adverse drug events. (2019). Patient Safety Network. Web.

Nguyen, M. N. R., Mosel, C., & Grzeskowiak, L. E. (2018). Interventions to reduce medication errors in neonatal care: A systematic review. Therapeutic Advances in Drug Safety, 9(2), 123-155. Web.

Prgomet, M., Li, L., Niazkhani, Z., Georgiou, A., & Westbrook, J. I. (2017). Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: A systematic review and meta-analysis. Journal of the American Medical Informatics Association, 24(2), 413-422. Web.

Shah, N., & Jani, Y. (2020). Implementation of smart infusion pumps: A scoping review and case study discussion of the evidence of the role of the pharmacist. Pharmacy, 8(4), 239. Web.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dispensing errors and prevention. StatPearls Publishing.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication Administration Errors and Associated Factors Among Nurses. International Journal of General Medicine, 13, 1621. Web.

Wittenberg, E., Ferrell, B., Kanter, E., & Buller, H. (2018). Health literacy: Exploring nursing challenges to providing support and understanding. Clinical Journal of Oncology Nursing, 22(1), 53-61. Web.

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