Prevention of Medication Errors Kelly Cullinan, Abigail Jackson, Kristina Nealy & Jamie Steele Quality Improvement Objective
After our clinical experiences and conductive research we have concluded
that barcode medication administration scanning systems are not always easily accessible; therefore, they are not always utilized which puts patients at higher risk for medication errors. Our objective is to improve medication safety and reduce the incidence of medication errors with the use of barcode medication administration scanning systems. Medication Errors
A medication error is any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer 1 . According to the FDA, at least one death per day and approximately 1.3 million injuries a year, are due to medication errors. This makes medication errors the number one cause of sentinel events in hospitals 1. Medication Errors Statistics
According to Cabilan, Hughes, and Shannon, medication errors occurred
during the following stages of medication administration 2:
During administration (62.7%)
Prescribing (28.6%) Commonly during both stages (18.5%) Aim Statement: Reduce the occurrence of medication administration errors made in hospitals by increasing access to and use of barcode scanning systems. Root-Cause Analysis Team: Nurses, pharmacists, & computer technologists Current approach: Five rights of medication administration - Verifying the right patient, right medication, right route, right dose and right time while independently force completing medication administration. Barcode Point Of Care systems are believed to be effective in preventing medication administration errors but are currently implemented in only about 2% of U.S. hospitals 3.
A meta-analysis study conducted in 2015 reported a 57.5% reduction of
medication errors after fully implementing the barcode scanning system 4. Increase the number of WOWs (workstation on wheels) in units, barcode point of care systems in each patient room. Check the integrity of the wrist band and renew this band periodically 5 Print the barcode against a white background on transparent drug transfusion bags 5 Demonstration the skills of barcode scanning to nurses and inspect the function of scanners periodically 5 Increase the number of access points for the wireless network 5 Demonstrate the procedure for adjusting the sound volume on the scanner 5 Medication Errors will decrease in percentage in units this program is implemented in. Will record data by having nurses self audit if utilizing barcode scanner Initiate a study to evaluate the incidence of medication errors within the hospital before and after implementation Audit patients electronic medication administration records (eMAR) to ensure medications are being scanned, rather than force completed Compare nurses self audit for barcode use with reviewing the patient's eMAR Regularly utilize chart auditing to evaluate scanning compliance Provide regular educational courses on barcode scanning How to use barcode medication administration system How to utilize modifying factors of the system for appropriate use Require education with system updates Provide rewards and incentives for using the barcode medication administration system and attending educational seminars 5 Evaluate study for incidence of medication errors with implement of barcode medication administration scanning Implement improvements as necessary per research 6 References 1. Center for Drug Evaluation and Research. (2016). Medication errors - Medication error reports. Retrieved from https://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm 2. Cabilan, C., Hughes, J. A. and Shannon, C. (2017), The use of a contextual, modal and psychological classification of medication errors in the emergency department: a retrospective descriptive study. Journal of Clinical Nursing. doi: 10.1111/jocn.13760 3. Sakowski, J, , Leonard, T., Colburn, S., Michaelsen, B., Schiro, T., Schneider, J., Newman, J. (2005). Using a Bar-Coded medication Administration System to Prevent Medication Errors. American Journal of Health-System Pharmacy. Retrieved From http://www.medscape.com/viewarticle/519719?trendmd-shared=1&src=trendmd_pilot. 4. Khammarnia, M., Kassani, A., & Eslahi, M. (2015). The efficacy of patients wristband bar-code on prevention of medical errors: A meta-analysis study. Applied Clinical Informatics, 6(4), 716727. Doi: 10.4338/ACI-2015-06-R-0077 5. Yen, Y. T., Chang, S. F., Tsai K. L., Chen C. J., Liu, L. C., Fang, Y.C. (December 2015). A program to improve the implementation rate for the barcode medication administration system. 62(6) 90-7. doi: 10.6224/JN62.6.90 6. Mims, E., Tucker, C., Carlson, R., Schneider, R., Bagby, J. (2009). Quality-monitoring program for bar-code-assisted medication administration. American Journal of Health-System Pharmacy, 66, 1125-1131. doi: http://dx.doi.org.ezproxy.hsc.usf.edu/10.2146/ajhp080172