IDENTIFYING MODIFIABLE BARRIERS IN THE ONLINE … · Web viewShe currently lives in Spofford, New Hampshire where she can enjoy everything the outdoors has to offer. Besides working

Identifying Barriers In The Online Medication Error Reporting System:

A Quality Improvement Initiative

By

Jessica P. Lerner

Bachelor of Science in Biology, Saint Lawrence University, 2009

CAPSTONE PROJECT

Submitted to the University of New Hampshire

in Partial Fulfillment of

the Requirements for the Degree of

Master of Science in Nursing

December, 2011

This Capstone Project has been examined and approved.

______________________________________________________

Joan Earle Hahn, PhD, APRN, GCNS-BS, GNP-BC, CDDN

Associate Professor in Nursing

Committee Chairperson

__________________________

Date

ACKNOWLEDGEMENTS

This quality improvement initiative would not have been possible without the

support of many people. I would like to express my deepest gratitude to Nancy Crawford,

MS RN CCNS Acute Care Clinical Nurse Specialist who was extremely helpful and

offered invaluable assistance, support and guidance. I would also like to thank the staff at

the study hospital including the Webmaster and the members of the Nursing Quality

Improvement Council, who in one way or another contributed and extended their

assistance in the preparation and completion of this project. A special thank you to the

professors at UNH and the DEMN cohort 7 who provided invaluable assistance during

this QI project. Finally I would like to thank my family for their endless love and support

during the past two years.

iii

BIOGRAPHY

Jessica Lerner is a graduate from Saint Lawrence University where she majored in

Biology. Jessica is part of the National Student Nurse Association and the Golden Key

International Honors Society. She currently lives in Spofford, New Hampshire where she

can enjoy everything the outdoors has to offer. Besides working on her master’s degree,

Jessica spends her time drawing, skiing and hiking with her rescue dog Murphy.

Fulfilling her dream of becoming a nurse, Jessica also plans to become a qualified

therapy dog trainer.

iv

TABLE OF CONTENTS

Acknowledgements……………………...…………………………………………...iii

Biography………………………………………….………….……………………....iv

Table of Contents……………………………………..………………….………..…..v

Abstract ……………………………………………….…………...………………...vii

Background……………………………………………..……………...……………...3

Local Problem……………………………………………..……….…...........……......6

Aims………………………………………………………….…….............……….....7

Methods………………………………………………………….……………….........8

Ethical Issues & Confidentiality …………………………....…………………8

Setting………………………………………………………….………........…9

Study Questions…………………………………………………...…………..9

Project Framework………………………………………………….…...........10

Planning the Intervention………………………………………….….............11

Methods of Evaluation………………………………………………..……....13

Results………………………………………………………………………….…….13

Quantitative Results…………………………………………………..……....13

Table 1- Summary of Key Survey Results………………………..…..17

Qualitative Results……………………............................................................17

Discussion………………………………………………………………………........19

Summary of Results…………………………………………………………..19

Limitations……………………………………………………………….…...22

CNL Perspective………………………………………………………..........23

Recommendations………………………………………………………....................23

Conclusion …………………………………………………………………………..23

References…………………………………………………………..……...……...…25

Appendix…………………………………………………………………………......27

Appendix A ………………………………………………………………..…28

Appendix B ………………………………………………………………..…29

Appendix C ……………………………………………………………..……30

Appendix D ……………………………………………………………..……37

v

Appendix E ………………………………………………………………..…38

Appendix F …………………………………………………………..……….41

vi

ABSTRACT

IDENTIFYING MODIFIABLE BARRIERS IN THE ONLINE MEDICATION ERROR

REPORTING SYSTEM: A QUALITY IMPROVEMENT INITIATIVE

Jessica P. Lerner, B.S, R.N

University of New Hampshire, Dec. 2011

Background: Medication errors are common, preventable, costly, and may result in

patient harm. The decrease of errors has received increased attention in creating a culture

of safety. Healthcare staff are encouraged to report medication errors and near misses to

identify opportunities for improvement. Aim: The purpose of this project was to evaluate

the online medication error reporting system, its roll-out process and nurses’ knowledge

and attitudes concerning medication errors at a rural hospital in New Hampshire.

Method: A quantitative and qualitative analysis of the reporting system was conducted.

Nurse leaders/educators on each of the nine units in the hospital were interviewed using a

standard set of five questions. Staff nurses on each unit completed a 20-item online

survey. Results: Eight interviews were conducted. Sixty-five staff nurses completed the

online survey for a response rate of 40.6%. Conclusion: Based on the survey responses

the online tool is easy to use, nurses have a sufficient knowledge base surrounding

medication error and unit discussions about the errors would be beneficial. Unit leader

interviews showed there was no controlled rollout process for the online reporting system

and feedback concerning medication errors and trends is dependent on the unit leader.

Efforts to improve medication error reporting should focus on increased feedback to staff

nurses and a new organized rollout plan to inform staff with periodic reminders.

vii

Running header: Barriers to Online Medication Event Reporting 1

IDENTIFYING MODIFIABLE BARRIERS IN THE ONLINE MEDICATION ERROR

REPORTING SYSTEM: A QUALITATIVE AND QUANTITATIVE ANALYSIS

Medication errors are among the most common, costly and preventable causes of

patient harm (Handler et al., 2007). Common practice in the United States, to decrease

mistakes involving medications, is the reporting of medication errors and collection of

data (Evans et al., 2006). To decrease mistakes that occur with medications healthcare

professionals may collect data on medication errors and identify why they occur and how

they may be avoided in the future. The Institute of Medicine (IOM) has recommended a

thorough and systematic approach to documenting medication errors in order to identify

trends and prevent similar mistakes from occurring in the future (Aspeden et al., 2007).

Systematic reporting of medication errors can lead to a better understanding of the root

causes of errors and identify opportunities for improvement (Handler et al.). For

medication error reporting to be successful the tool must be appropriately utilized by the

healthcare team. Incomplete reporting will provide little information on medication errors

and inaccurate data on the occurrences and trends in errors.

In 2010 a rural community hospital in Southern New Hampshire adopted a new

electronic medication error reporting system. The electronic system replaced an

anonymous “pink slip” system, a piece of paper and a drop box on each unit, which was

sent monthly to the quality improvement department. The pink slip system received poor

utilization; the recording system for medication errors was receiving insufficient amount

of data to assess accurate medication error rates and trends that would help identify

opportunities for improvement in patient safety. In April, 2010 (Third Quarter) the

organization rolled out an electronic medication error reporting system that allowed

i

Barriers to Online Medication Event Reporting2

healthcare professionals to record a medication error directly on the MAK (the electronic

medication system) or on the hospital’s Intranet. Once the new system was initiated the

organization saw a peak in medication error reporting, not because more errors were

occurring but nurses, physicians and pharmacists were more diligent about reporting

recognized medication errors.

Peak utilization of the online medication error-reporting tool was identified on

specific units and remained low on other units after the initiation of the online tool. After

three months the number of reports steadily declined and after a year the reporting of

medication errors has dropped significantly, with some units not reporting any

medication errors. The Nursing Quality Improvement Council had identified medication

administration safety as a top priority.

To ensure that knowledge surrounding medication errors and the medication error

reporting system is utilized, new nurses to the study hospital/organization receive in-

service during orientation. The in-service includes medication safety, medication events

and how to access the online reporting tool at the time of a medication event. The

purpose of this project was to identify barriers in the use of the electronic reporting

system and find areas for improvement that may include improving nursing knowledge of

medication errors and the reporting system, such as how it serves as an important tool for

improving patient safety. The project was designed to identify knowledge, attitude, and

organization-system barriers to the online reporting system among nursing staff. The goal

of the quality improvement project was to identify barriers to the use of the reporting

system and help initiate an ongoing improvement process surrounding medication errors

and patient safety.


Background

Medication errors have been identified as the most common type of error affecting

the safety of patients and the most common preventable cause of adverse events

(National Medicine Information Centre, 2001). The Institute of Medicine (IOM) and the

Leapfrog Group both support voluntary and confidential reporting of medication errors to

increase patient safety (Armitage, 2010). According to the IOM about 1.5 million people

suffer from medication incidents and up to 98,000 deaths occur each year due to

medication errors (Kohn, Corrigan, &Donaldson, 2000). By promoting the reporting of

medication errors health organizations can gather data and information on the occurrence

of medication errors and identify opportunities for improvement. Thus, the reporting

system of medication errors is a useful tool for improving patient safety. Evident in the

literature, medication errors are widely underreported and as a result information on

medication errors, recognizing trends, discovering causal factors and identifying

preventative measures are inadequate (Armitage, Newell, & Wright, 2010; Alrwisan,

Ross &Williams, 2011; Kelly, 2004). Barach and Small (2006) reported that

underreporting occurs at a rate of 50 to 96 percent in the United States. Baker et al.

(2002) found that medication errors occur in approximately one out of every five doses in

a typical hospital. Those medication errors that are most frequent, from Baker et al.

(2002) study were wrong time of administration, omission and wrong dose. The evidence

provided by Baker et al. (2002) support the IOM report that medication delivery and

administration systems of the nation’s hospitals have major problems.

Previous hospital based studies determined that the most common barriers to

incidence reporting included: not receiving feedback once submitting a report; not having


the knowledge base to know which medication errors should be reported; and not having

a readily available reporting system (Evans et al., 2006; Handler et al., 2007; Miller et al.,

2006; Kingston et al., 2004). Uribe et al. (2002) found that the most modifiable barriers

to medication error reporting systems, based on responses from nurses and physicians

included: not being able to report anonymously; not understanding the usefulness of the

reporting, and the knowledge deficit surrounding what errors are reportable.

The culture of an organization can have a major affect on whether new technology

and processes are adapted or not (Kingston et al., 2006). For instance a culture that

fosters punitive environments leads nurses to be defensive and may cause them to feel

threatened by the organization’s response to errors.

The culture of the organization is crucial to foster a change environment. In order

for technology and change to be accepted by the nursing staff it should include an

adequate learning process and a planned implementation (Porter-O’Grady & Malloch,

2011). Considerable care is needed to implement technology into a health care system.

Success of new technology in an organization is dependent on the participation of the end

users during the development process, time to adequately prepare the end users, attention

to site-specific concerns, and consideration of the end users workflow process (Garret et

al., 2006). To achieve adoption of new technology it must first be conveyed to the

healthcare team that the new technology will not increase their work load but instead fit

seamlessly into current workflow and have an observable impact for improving workflow

and patient care (Garret et al., 2006).

The hospital in which the quality improvement project took place supports a

confidential, non-punitive, system based approach to the identification and reporting of


medication occurrences. The hospital recognizes that medication errors are not caused

intentionally by individuals, but are largely the result of a system that needs continuous

improvement. This is supported by the IOM, The Joint Commission and The National

Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) who

all recommend that healthcare organizations reward people for reporting errors and that

focus should be placed on improving the system rather than blaming the individuals

(Aspden et al., 2007; Jaffe et al., 2004; NCC MERP, 2005).

Within the study hospital, to identify and address the systems needs, medication

occurrences are reported to the Quality Improvement Department (QI) which completes

data analysis and then reports it to the Medication Management Team quarterly. The

Medication Management Team works with the Clinical Monitoring Committee and

Patient Safety Committee to review the information and develop prevention and risk

reduction strategies to decrease medication occurrences.

The study hospital defines an actual medication event as one that occurs when a

patient received an incorrect drug, drug dose, dosage form, amount, route, concentration,

administration rate; or omission. A near miss is considered a medication discrepancy of

recording, dispensing, profiling, or prescribing which is discovered prior to the patient

receiving the medication. Nurses, physicians and pharmacist are encouraged to report

both actual medication occurrences and near misses.

The NCC MERP (2005)define medication errors as:

“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. Such events may be related to professional practice, health care


products, procedures, and systems, including prescribing, order communication,

product labeling, packaging and nomenclature, compounding; dispensing,

distribution, administration, education, monitoring and use.”

Medication errors continue to be one of the leading causes of salient events in the

health care industry. These are preventable errors that may cause great harm and

jeopardize the safety and quality of care provided for patients. Innovative approaches

need to be implemented to address this problem of the under reporting of medication

errors.

Local Problem

In 2009 the Culture of Safety Survey indicated medication errors were an area of

concern. Underreporting was evident with the pink slip reporting system. The pink slip

system was replaced by the occurrence report during the first quarter of 2010. The

occurrence report was a broad reporting system for any occurrence that occurred at the

hospital including medication errors and falls. The initiation of the occurrence report

correlated in increased medication event reports yet it was perceived that medication

events continued to be underreported. In 2010 the reporting form was redesigned

exclusively for medication events (see Appendix A). The new online form allowed for

immediate reporting on the study hospital’s Intranet or directly on the medication

administration system (MAK). With the rollout of the online reporting tool during the

third quarter of 2010 there was a subsequent peak in the amount of medication events

reported, almost double the amount of medication events reported in the previous quarter

(see Appendix B).


Since the initial rollout of the online medication event form the amount of

medication errors and near misses reported has declined. A member of the Quality

Improvement Department identified medication event reporting as a particular area of

concern. Medication errors were occurring on each of the units but were being

underreported, greater under reporting on specific units. Based on the data obtained from

the first quarter of 2011, some units reported no medication errors or near misses during

this period.

The goal of this QI project focused on identifying the barriers to medication error

reporting and increasing efforts to encourage medication error reporting by nurses, who

administer a significant amount of medications in the study hospital. The Nursing Quality

Improvement Council has made medication safety a priority and provided the support for

this quality improvement initiative. A Clinical Nurse Leader (CNL®) (AACN, 2007)

student assumed a leadership role to address the priority issue of low rates of medication

error reporting.

Aims

The global aim of this project was to promote an environment of patient safety by

decreasing the amount of medication errors. Medication errors are among the most

common and preventable causes of patient injury (Handler et al 2008). Promoting a

system that addresses this concern will increase patient safety in that particular

environment.

The specific aim of this QI project was to identify the reason behind the

underreporting of medication errors among nurses on the nine hospital units. The central

question asked what barriers are interfering with the medication error reporting that


prompt its underuse. A secondary question was formulated to take a retrospective look at

the process of introducing the new system to the nurses. Identifying modifiable barriers to

the current system will provide opportunities for improvement, encourage the reporting

of medication errors among nurses and help create a system that will improve medication

error reporting.

Methods

Ethics Issues & Confidentiality

Based on the literature medication errors occur in every hospital all over the world

and many hospitals face the issue of underreporting (Barach & Smalls, 2000). Although

these are global issues addressed in this QI initiative, the study hospital was kept

anonymous in the report. During the research process and project presentation the

hospital was not identified and confidentiality was maintained. The organization was

referred to as a rural community hospital in Southern New Hampshire. This action was

taken to maintain confidentiality, which had been requested by the quality improvement

department.

The institution’s executive nursing management approved the methods used for

the quality improvement project prior to implementation. No ethics review was required

by an institutional review board as information gathered in this project aimed to improve

patient safety and was not collected for the purposes of providing generalized knowledge

(e.g. research). Participants in the project were assured confidentiality. It was explained

to each of the participants that the results from the questionnaire and interviews would be

reported in such a way that no person would be identified.


Setting

The quality improvement project took place in an accredited general medical and

surgical rural community hospital in Southern New Hampshire. Only patient care units

that used the same online medication error reporting form were included in the project.

Nine units were selected to participate in the study. Between 150 and 170 registered

nurses and licensed pratical nurses work on these units. The project was designed and led

by a CNL® student. The design of the study, including the survey and guided questions

for unit leaders, was reviewed by the chair of the Nursing Quality Improvement Council

and the onsite clinical nurse specialist serving as preceptor. Invaluable assistance was

provided by the hospital Webmaster.

A mixed method approach using a qualitative and quantitative descriptive design

was used to answer this complex problem. The quantitative method that was used to

gather information from the staff nurses will be described first. This will follow with a

description of qualitative method that was aimed to gather information from the unit

nurse leaders.

Study Questions

The central question that this quality improvement addressed was: What barriers

are interfering with medication error reporting prompting its underuse? Secondary

questions were formulated to take a retrospective look at the process of introducing the

new system to the nursing staff:

1. Was there collaboration among the nurses and leaders in the creation and

implementation of the electronic reporting system?


2. Was the system rolled out in an coordinated manner based on knowledge of

change process?

3. Were the unit nurse leaders/educators involved in the development of the

system?

4. Were the unit nurse leaders/educators knowledgeable about the system and

5. What were the methods used by the leaders to introduce the system to the

nurses on each unit?

Project Framework

The Dartmouth Microsystem Improvement Ramp was used during the quality

improvement initiative. The improvement ramp is a way of creating an organized step-

by-step picture of the quality improvement process that will act as a guide during the on-

going project. The improvement ramp is a systematic approach to quality improvement

goals that begins at the microsystems level. If the tested change is successful in the

microsystem it can then be implemented at the macrosystem level.

The Plan Do Study Act (PSDA) model is a model to implement change that is

followed by the Standardize Do Study Act (SDSA) cycle, which is a model used to then

standardize the change throughout the organization (Nelson, Batalden, & Godfrew,

2007).

At the time of this quality improvement project, the study hospital had already

implemented a hospital wide change by introducing the online medication event-

reporting tool in 2010. The goal of this quality improvement initiative was to study the

change and how it may be better utilized in the study hospital.


Planning the Intervention

On-line staff nurse survey. The quantitative portion of the project looked at the staff

nurses knowledge and attitudes about the medication reporting system, medication errors,

and creating a culture of safety. A twenty-item online survey, formulated on a survey

application by the Webmaster at the hospital, was developed and access was provided to

each of the nurses working on the units (see Appendix C). The survey was evaluated for

content validity by the Chair of the Nursing Quality Council, the acute/critical care

clinical nurse specialist, and a representative from the Quality Improvement (QI)

Department. The survey was restructured to fit the specific needs of the organization and

goals of the improvement project. Announcements about the survey and dates were

posted on each of the units. An announcement was also posted on the study hospital’s

intranet homepage that included a link to the survey. Nurses also received email

notification about the survey during the two weeks it was available that included a link to

the survey.

The survey included an introduction that explained the project and defined terms

that were used in the survey. Survey respondents used a 5-point Likert scale to score

factors in terms of agreement to statements concerning medication errors and reporting.

Each of these units use the same medication administration program and use the same

online form for reporting medication errors. Only units which used the same online

reporting form were included.

The online questionnaire asked questions that gauged the degree of likelihood an

item was a barrier to the reporting system. The questionnaire included questions directed

at the education process of the new online reporting system, attitudes toward medication


errors, knowledge of medication errors and near misses, importance of reporting of

medication errors/near misses, and problems with the new system. The questions used in

the survey were categorized into one of the following;

• Demographic: Nurses’ characteristics (license, unit, years of experience)

• Knowledge: Awareness about the facts concerning medication safety, the

reporting tool, and medication events.

• Attitude: Perception or feelings toward medication safety, the reporting tool,

and medication events.

• System: In-service instructions on the reporting tool and the ease and use of

reporting tool.

Unit interview

For the qualitative analysis unit nurse leaders and nurse educators on each unit

were interviewed with a standard set of five questions used to guide the interview. The

nurse leaders contacted for interviews represented the nine units.

It should be noted that that one interview was not completed with the leader of unit

4 who had recently retired and was no longer available. Instead nurses from unit 4 who

were present during the initial rollout of the online reporting system were questioned

about the education process on the unit and use of the tool. Multiple attempts were made

to interview the nurse leader on unit 2 but all were unsuccessful. Another nurse in a

current leadership role on that unit was interviewed but she declined to answer because

she was not aware of the roll out efforts for the medication error form during the period

in question.


Each interview was scheduled to take twenty minutes with an additional five-ten

minutes for comments and questions. The unit nurse leaders were asked questions about

the roll-out process of the reporting system, if they were involved or had collaborated

with the Nursing Quality Council to help create the reporting tool, how they informed the

staff nurses working on their unit about the reporting system, what information they

receive about medication errors reported from their unit and what they do with that

information (see Appendix D). The answers the unit nurse leaders/educators provided

were written down during the time of the interview. The notes from each nurse manager

interview were analyzed using the qualitative method of content analysis by the

interviewer to identify specific themes.

Methods of Evaluation

The interviews and surveys helped identify barriers to the electronic reporting

system. To assess this improvement project the response rates of the nurses in each of the

categories will be evaluated. If improvement is achieved use of the electronic medication

error reporting system will increase. This will be evaluated by the tracking of raw

numbers of reports from each unit. By having more reports, trends can then be identified

and provide a greater understanding of medication errors and their underlining causes.

Results

Quantitative Results

The survey received a strong response rate of 40.6%. Registered Nurses (RNs)

from each of the nine units participated in the survey. Out of sixty-five surveys that were

completed only one survey was completed by a Licensed Practical Nurse (LPN). The

majority of nurses (69.2%) who completed the survey had ten years or more of


experience. The survey revealed information about the nurses’ thoughts on the in-service

and the use of the medication event form and their knowledge and attitudes concerning

medication errors and the reporting tool. Barriers to the online medication error reporting

tool that have been identified in past studies were examined. The following summarizes

the key findings from the staff nurse survey:

Knowledge:

Five questions in the survey gauged the nurses’ knowledge on medication errors

and the online medication event form. When asked about the reportability of a medication

error or medication discrepancy, in which they were not directly involved, the majority of

nurses agreed (38.4%) or strongly agreed (47.6%) that it would be reportable by them.

Knowledge surrounding verification of medication orders, an essential step in medication

safety (NCC MERP, 2005) was strong in the study hospital. Verification of the original

physician’s order is important to safe medication administration and 81.5% of the nurses

strongly agreed. Always comparing the medication order on MAK (medication

administration computer) with the original written order was a statement to which 63% of

respondents strongly agreed.

It was thought that discussions about medication errors on their unit would be

beneficial by 79.8% of the responding nurses. One of the barriers to reporting medication

errors identified in past studies was the lack of feedback on medication errors (Uribe et

al, 2002).

The Nursing Quality Improvement Council, at the study hospital, is made up of a

group of nurses who coordinate and monitor the appropriateness and effectiveness of care


provided by nurses. Medication safety was declared a top priority in the study hospital, a

fact of which 75.3% of the responding nurses were aware.

Attitude:

Six questions were asked concerning the attitudes of the nurses at the study

hospital. These questions reflect the culture surrounding medication errors and the

reporting tool at the study hospital. Questions categorized as attitude questions focused

on the mental position one has with regard to medication safety, medication events, and

the online reporting tool. These questions were asked to gauge the influence of nurses’

attitudes on the online reporting tool.

A medication error that does not result in patient harm is reportable by 93.8% of

the respondents and a near miss that does not result in patient harm is reportable by

79.2% of nurses who participated in the survey. Whether a medication error or

discrepancy resulted in patient harm or did not, the majority of nurses agreed that it

would be reportable.

Distractions and interruptions during medication preparation and administration

are believed to be a leading factor in medication errors by 76.9% of nurses. This validates

the current initiative for practice change by the Nursing Quality Improvement Council

focusing on interruptions and distractions during medication administration.

The inability to report a medication error anonymously has been identified as a

barrier to medication error reporting in past studies (Sarvadikar, Prescott, & Williams,

2010; Jaffe et al., 2004). Anonymity around medication errors allows for nurses to report

an error without fear of repercussions from the organization. The majority of nurses who


responded to the survey (55.3%) are not concerned that being involved in a medication

error would negatively impact their performance evaluation.

System:

Six questions in the survey were categorized as a System issue such as in-service

about the tool and ease of use of the tool. During the initial rollout of the medication

event form or during new nurse orientation 60% of the nurses disagreed or strongly

disagreed with the statement, “I have received in-service instructions on the use of the

online medication event form.” Nurses who had received in-service instruction about the

online reporting tool made up 29.2% of respondents.

When it came to ease of use of the reporting tool 53.9% agreed that it was

available and easy to use at the time of a medication event, while 15.4% of nurses

disagreed. At the time of discovery of a medication error or near miss 55.3% of nurses

state they complete the online medication event form while 18.5% stated that they do not.

Nurses who agreed that they had used the online reporting tool in the past to report

an actual event made up 44.6% of respondents, while 46.1% agreed that they had used

the online reporting tool to report a near miss. When asked if they would be more likely

to report a medication event online, having completed this survey, 47% agreed while

28.7% disagreed.


Table 1

Summary of Key Survey Results

Knowledge PercentStrongly agree that verification of the original physician's order is important to safe medication administration. Agree that a medication error or near miss, in which one was not directly involved, is reportable by the individual that discovers it. Agree that discussions about medication errors on the unit would be beneficial.

When verifying a medication order always compare the order on the patient's chart with the original written order.Are aware about the Nursing QI Councils top priority concerning medication safety.

81.5%

86.0%

79.8%

83.0%

75.3%

AttitudeAgree that a medication discrepancy that does not result in patient harm is reportable.

Agree that competent nurses may make errors during medication administration.

Do not believe involvement in a medication error would negatively impact their performance evaluationBelieve that medication errors are often a result of inattention and carelessness. Agree that a medication error that does not result in patient harm is reportable. Agree that the majority of medication errors are due to interruptions and distractions during medication preparation and administration.

79.9%

79.2%

55.3%

36.8%

93.8%

76.9%SystemDid not receive in-service instructions on the use of the online medication event form. Agree that the online medication event form is available and easy to use at the time of a medication error or discrepancy.

Have used the online medication event form to report a medication error.Have used the online medication event form to report a medication discrepancy. Complete the online medication event form when a medication error or discrepancy is discovered. Would be more likely to report a medication error or discrepancy having completed the survey.

60.0%

53.9%

44.6%46.1%

55.3%

47.7%

Qualitative Results

Eight interviews were conducted with the unit nurse leader/educators. Two of the

nurse leaders did not hold their current role during the roll-out process of the online

medication event form. Long term nurses on these units were questioned for clarification

(see Appendix F).


During the development stage of the medication event form 33.3% of the unit

leaders/educators were involved in the development process, 44.4% were not involved

and 22.2% are unknown. Once the online medication event form was developed the tool

was reviewed during a unit leader council meeting.

The unit nurse leaders/educators were responsible for educating the staff nurses on

their unit about the new online tool. Of the unit nurse leaders that were interviewed

12.5% of the nurse leaders held an in-service about the tool during a floor meeting.

12.5% of the unit nurse leaders announced the new form during a floor meeting.

Nurse leaders that sent information to the staff in a unit weekly email, along with

the original hospital wide email, represented 25.0% of the nurse leaders. Unit

leaders/educators who used a hospital wide email about the new online medication event

form as their only approach to staff education made up 50.0% of unit nurse

leaders/educators.

When a medication event form is completed it is sent to the quality improvement

department. A copy of the form is then sent to pharmacy and to the nurse leader, on

whose unit the event was reported. Unit leaders who collect the reports, identify themes

and discuss medication events with the staff nurses made up 12.5% of the unit leaders.

Leaders who collect and identify themes but held no discussion on the unit represented

25% of unit nurse leaders. Reports that identify a sentinel event, an event that resulted in

patient harm or had the potential to harm a patient were the only medication events that

were addressed by 12.5% of the unit nurse leaders. Units which have no follow up or

discussion about medication events make up 37.5% of the units.


The Quality Improvement Department tracks hospital wide trends and reports to

the Nursing Quality Improvement Council quarterly on events reported by nurses.

Information about medication events, provided by quality improvement, including unit

specific events and trends does not reach 77.7% of the unit nurse leaders/educators.

Discussion

Summary of the Results

Patient safety has been an important issue during the past decade in Europe and the

United States, as there has been growing concern about the preventable harm attributed to

medical errors (Alrwisan, Ross &Williams, 2011). Improving the reporting of medication

events will provide stronger data on the root causes of medication errors and may help

decrease the prevalence of medication events and the potential harm they could have on

patients. This quality improvement initiative, which included the staff nurse surveys and

the unit leader/educator interviews, has provided information concerning barriers to the

current online medication event reporting system at the study hospital.

Based on the results of the survey it is agreed that the study hospital’s culture

surrounding medication errors and the reporting system is non-punitive. Kelly (2004)

identified fear as one of three primary reasons for underreporting of medication events. A

non-punitive culture is vital to the success of a reporting system that tracks errors. Nurses

who are in fear of job security are less likely to report a medication error if they believe it

may harm their career in the future. Nurses are likely to feel threatened by an

organization response to error if it is a punitive environment (Evans et al 2004).

Nurses generally agree that the online form is available and easy to use at the time

of a medication event. This is crucial for technology to be successfully implemented into


an organization. Technology that is available and easy to use, one that fits seamlessly into

the workflow process of the end users, is more likely to be used effectively (Garret et al.

2008). Nurses who disagreed with the statement that the online tool is easy and available

to use are less likely to have reported a medication event in the past and are less likely to

report a medication event at the time it occurs.

The knowledge base regarding medication errors among nurses on the nine units is

strong. Based on the results, nurses understood when to report a medication error or near

miss, had sufficient knowledge surrounding medication safety and understood who would

be responsible to report a medication error once discovered.

Based on the results there is an agreement that on-unit discussion of medication

errors would be beneficial. One of the barriers to the online reporting system identified in

multiple interviews with unit nurse leaders/educators was the lack of feedback the staff

nurses receive on medication events and trends. It was suggested that when nurses are not

included in the discussion of the reported medication events or trends identified, there is a

general lack of understanding behind the purpose of the reporting tool. When staff nurses

are left out of the conversation they may become uninformed about steps being taken to

address issues of concern. It is suggested that feedback could improve adherence to

medication event reporting by providing the observable impacts it can have on improving

workflow and patient care (Garret et a., 2006). Survey participation among staff nurses

alone resulted in increased awareness of the reporting tool and increased medication

event reports on some units.

Nurses who completed the online survey identified distractions and interruptions

as a significant factor to medication events. The nursing quality improvement council at


the study hospital is currently focusing on interruptions and distractions during

medication preparation and administration. Distractions and interruptions has been

acknowledged as a significant factor, based on the survey responses, and therefore

validates the nursing QI council focus for practice change.

Interviews with the unit nurse leaders/educators provided significant information

on the change process used during the rollout of the online medication event tool and the

follow up process currently being utilized. Based on the responses from the unit leaders

and educators there was no controlled hospital wide rollout process of the online

reporting system in April 2010. The unit leaders/educators were responsible for

educating the staff about the new tool on the unit. The majority of unit leaders/educators

sent an email to the unit staff informing them about the new system. Based on current

best practice methods new technology must be implemented in a systematic planned

process for the technology to be successfully adopted by the staff (Garret et al., 2008).

Based on the feedback from the unit leaders/educators there is a general lack of

feedback from the Quality Improvement (QI) Department on the trends in the medication

errors and discrepancies. Unit leaders receive a medication event report each time a

report is submitted by a nurse on the unit but may benefit more from trends indentified

from QI.

When asked about perceived barriers to the online medication event system the

majority of unit leaders/educators stated that there is a knowledge deficit concerning

reportable medication errors by staff nurses. Although past research had identified a

knowledge deficit concerning medication event reporting among nurses as one of the


highest barriers to medication error (Handler et al, 2007) the responses from the staff

nurse survey disputes this perception at the study hospital.

Nurses from unit two and unit seven, who completed the online staff nurse survey

were less likely to agree that they had received sufficient in-service instructions on the

use of the online medication event form (mean of 72.7%). Unit two and seven were

identified, by the QI department, for lack of use of the online medication event system.

This finding suggests that lack of in-service instruction leads to deficient system use. It

was noted that nurses with less than two years of experience were more likely to have

received in-service on the use of the online medication event form (80%). This suggest

that the information provided during new nurse orientation on medication safety and the

online reporting tool is effective.

Limitations

To best measure the accuracy of medication error reporting, The NCC MERP

suggests that a review of all medication orders be extensively evaluated for past

medication errors during a certain time to get a accurate rate of medication errors for the

particular facility (NCC MERP, 2005) since all organizations are different and will have

different rates. This measurement was not done and there is no known medication rate for

this organization.

The current QI initiative focused exclusively on nurse reporting of medication

events. Other member of the healthcare team who also have a duty to report medication

events and in the study hospital would be using the same reporting tool, were not

included.


CNL® Perspective

This QI initiative has been developed to address the issue concerning the

underreporting of medication errors from the perspective of the CNL®. The role of the

CNL® includes working collaboratively with interdisciplinary team members to improve

and coordinate patient care and safety. A CNL® s’ education prepares them to utilize the

best available evidence by integrating it seamlessly into practice. An individual trained as

a CNL® is prepared to lead quality improvement initiatives at the microsystem level by

using a quality improvement model, such as the PSDA cycle.

RecommendationsData gathered to date for this QI project supports potential improvements in the

online medication error system. Recommendations at this time include:

• Regular feedback to each unit from QI on reported medication errors, near misses

and identified trends.

• QI to track trends with increased utilization of the online medication error form

and make recommendation for improvements to appropriate committees.

• A new organized, hospital wide rollout plan to educated staff about the online

medication error from with planned periodic reminders.

ConclusionIn healthcare the rate of errors involving medications are substantially high, have

the potential to cause considerable harm to patients and increased costs to organizations.

This QI initiative focuses on using error as a tool for improvement. Error is essential to

all progress and can be used to measure where a system is in relationship to a particular

endpoint ( Porter-O’Grady & Malloch, 2011). The reporting of medication events is an

important measure to understand their causes, prevent medication error incidents in


healthcare systems and can serve as an important tool for improving patient safety

(Sarvadikar, Prescott, &Williams, 2010). The continuation and completion of this QI

project will hopefully result in an improved system for medication event reporting, trend

analysis and improved interdisciplinary communications surrounding medication errors.


References

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Brady, A., Malone, A., & Fleming, S.(2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of Nursing Management, 17(6), 679-697. doi:10.1111/j.1365-2834.2009.00995.x

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Handler, S.M., Perera, S., Olsansky, E.F., Studenski, S.A., Nace, D.A., Fridsma, D.B., &Hanlon, J.T. (2007) Identifying Modifiable Barriers to Medication Error Reporting in Nursing Home Setting. Journal of the American Medical Directors Association, 8(9), 568-574

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Hession-Laband, E., & Mantell, P. (2011) Lessions learned: Use of event reporting by nurses to improve patient safety and quality. Journal of Pediatric Nursing, 26, 149-155

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Safety, 49, 35-41. Available at http://www.williamnkelly.com/PatientSafety.pdf

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APPENDICES


Appendix A

Online Reporting Tool


Appendix B

Number of Medication Errors Reported for Q4 2009 to Q3 2011

Quarter


Appendix CStaff Nurse Online Survey

Staff Nurse Online SurveyInstructions & Definitions

Instruction

The intent of this project is to help identify barriers to the current online medication error reporting system. This survey includes several different questions related to medication safety. There are no correct or incorrect answers and no trick questions. This survey will remain anonymous so please respond to each question honestly and accurately to the best of your ability.

This survey should take about 10 minutes but there is no time limit.

If you have any questions or technical difficulties please do not hesitate to contact Jessica Lerner at 603 361 2166 or [email protected]. To fulfill requirements for my DEMN (direct entry masters degree in nursing) I am requesting your participation in my Capstone project. The results will be shared with the Nursing Quality Improvement Council at study hospital and with my UNH class.

Thank you for your participation.

Definitions

(The following definitions will be used for the purpose of completing this survey)

Medication error (event) occurs when a patient receives an incorrect drug, drug dose, dosage form, amount, route, concentration, administration rate; or omission. (An actual event)

Medication discrepancy is a discrepancy of reconciling, dispensing, profiling, or prescribing which is discovered prior to the patient receiving the medication. (A near miss)

mailto:[email protected]


Staff Nurse Online SurveyDemographic Questions

What license do you currently hold as a nurse? Registered Nurse

Licensed Practical Nurse

Please select your home unit (where you predominately work) Unit 1

Unit 2

Unit 3

Unit 4

Unit 5

Unit 6

Unit 7

Unit 8

Cumulative years of experience as a nurse 0 to 2

3 to 5

6 to 9

10 or more



Staff Nurse Online SurveySurvey Questions 1- 4


1.) I have received in-service instruction on the use of the online medication event form. Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

2.) The online medication error reporting system is available and easy to use at the time of a medication error (actual event) or medication discrepancy (near miss).

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

3.)Verification of the original physician’s order is important to safe medication administration.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

4.) A medication discrepancy (near miss) that does not result in patient harm is reportable.

Strongly Agree

Agree

Neutral

Disagree


Staff Nurse Online SurveySurvey Questions 5-8


5.) I have used the online mediation error form to report a medication error (actual event) Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

6.) Competent nurses do not make errors during medication administration. Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

7.) I am concerned that being involved in a medication error would negatively impact my performance evaluation.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

8.) I have used the online medication error form to report a medication discrepancy (near miss).

Strongly Agree

Agree

Neutral

Disagree


Staff Nurse Online SurveySurvey Questions 9-12


9.) My discovery of a medication error (actual event) or medication discrepancy (near miss), in which I was not directly involved, is reportable by me.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

10.) Medication errors are often a result of inattention and carelessness Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

11.) Discussions of medication errors on my unit would be helpful to me. Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

12.) A medication error (actual event) that does not result in patient harm is reportable. Strongly Agree

Agree

Neutral

Disagree



Staff Nurse Online SurveySurvey Questions 13 - 15

13.) In verifying a physician’s order in the electronic medication administration record I always use the written order in the patient’s chart to compare it.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

14.) At the time of discovery of a medication error or medication discrepancy I complete the online medication error form.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

15.) The majority of medication errors are due to interruptions and distractions during medication preparation and administration.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree


Staff Nurse Online SurveySurvey Questions 16 -17

16.) I am aware that the study hospital Nursing Quality Improvement Council exists and that one of their top priorities is medication safety.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

17.) If a medication error or near miss occurred today, I would be more likely to report it having completed this survey.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree


Appendix D

Unit Nurse Leader/Educator Interview Questions

Questions for Unit Nurse Leaders/Educators

1.) Were you involved in the development of the online medication error reporting tool? Were you part of the group that developed it or did you contribute input or suggestions for the tool during the development process?

2.) Once the online medication error reporting form was developed what type of education or instructions did you receive on the use of the tool? Did you find it helpful? What were your initial thoughts about the tool?

3.) When the tool was rolled out in April, 2010 was there a plan or process you used to educate the nurses on the unit about the tool and how to use it? Do you think it was sufficient? If not, who at the time was responsible for educating the nurses? Did every nurse on the unit receive the same education about the tool?

4.) The online medication error reporting system has been in use since April 2010. Have there been any follow up on the utilization of the online medication error reporting tool? How well do you think the tool is used on the unit?

5.) Do you receive reports of medication errors and near misses? How often? Specific to your unit? What use do you make of these reports on the unit? Do you relay information on medication errors to the staff on the unit?

Any comments or thoughts?

How important do you consider medication error reporting? In your opinion, what are the current barriers to the reporting of medication errors?


Appendix E

Survey Response DataDemographic Data

Question 1:License Response Response Count

LPN 1.5% 1

RN 98.5% 64

Question 2:Home Unit Response Response Count

Other 12.3% 8

Unit 2 7.7% 5

Unit 3 9.2% 6

Unit 4 18.5% 12

Unit 5 6.2% 4

Unit 6 4.6 3

Unit 7 12.3% 8

Unit 8 18.5% 12

Unit 9 10.8% 7


Question 3: Years of Experience Response Response Count

0 to 2 7.7% 5

3 to 5 9.2% 6

6 to 9 12.3% 8

10 or More 70.8% 46

Knowledge Data

StatementStrongly Agree Agree Neutral Disagree Strongly

DisagreeNo

Answer

1. Verification of the original physician’s order is important to safe medication administration. 81.50% 13.80% 3.00% 0.00% 1.50% 0.00%

2. My discovery of a medication error (actual event) or medication discrepancy (near miss), in which I was not directly involved, is reportable by me. 47.60% 38.40% 9.20% 3.00% 0.00% 1.50%

3. Discussions of medication errors on my unit would be helpful to me. 26.10% 53.80% 13.90% 4.60% 1.50% 0.00%

4. In verifying a physician’s order in the electronic medication administration record I always use the written order in the patient’s chart to compare it. 63.00% 20.00% 12.30% 3.00% 0.00% 1.50%

5. I am aware that the hospital Nursing Quality Improvement Council exists and that one of their top priorities is medication safety. 36.90% 38.40% 10.70% 9.20% 4.60% 0.00%


Attitude Data


DisagreeNo

Answer

1. A medication discrepancy (near miss) that does not result in patient harm is reportable. 49.2% 30.7% 13.8% 4.6% 1.5% 0.0%

2. Competent nurses do not make errors during medication administration. 0.0% 3.0% 6.1% 32.3% 56.9% 1.5%3. I am concerned that being involved in a medication error would negatively impact my performance evaluation. 6.1% 18.4% 18.4% 43.0% 12.3% 1.5%

4. Medication errors are often a result of inattention and carelessness 7.6% 29.2% 23.0% 21.5% 16.9% 1.5%

5. A medication error (actual event) that does not result in patient harm is reportable. 64.6% 29.2% 1.5% 1.5% 3.0% 0.0%

6. The majority of medication errors are due to interruptions and distractions during medication preparation and administration. 24.6% 52.3% 18.4% 3.0% 1.5% 0.0%

System Data


DisagreeNo

Answer

1. I have received in-service instruction on the use of the online medication event form. 7.7% 21.5% 10.8% 26.2% 33.8% 0.0%

2. The online medication error reporting system is available and easy to use at the time of a medication error (actual event) or medication discrepancy (near miss). 15.40% 38.50% 27.70% 9.20% 6.20% 3.10%

3. I have used the online mediation error form to report a medication error (actual event) 32.30% 12.30% 6.20% 13.80% 32.30% 3.10%

4. I have used the online medication error form to report a medication discrepancy (near miss). 21.50% 24.60% 6.20% 16.90% 27.70% 3.10%

5. At the time of discovery of a medication error or medication discrepancy I complete the online medication error form. 21.50% 33.80% 23.10% 15.40% 3.10% 3.10%6. If a medication error or near miss occurred today, I would be more likely to report it having completed this survey. 18.50% 29.20% 24.60% 16.90% 10.80% 0%


Appendix F

Unit Nurse Leader/Educator Interview ResultsQuestion 1. Involvement in the development of the tool Response Response Count

Involved 33.3% 3

Not Involved 44.4% 4

Unknown 22.2% 2

Question 2. Education Response Response CountInvolved in the development of the tool, no education needed

33.3% 3

Educated during unit nurse leader council meeting

22.2% 2

Unknown 44.4% 4

Question 3. Education process for staff nurses Response Response Count

Unit in-service during unit meeting

11.1% 1

Announcement during morning meeting

11.1% 1

Weekly unit email 22.2% 2

Hospital wide email 100% 8


Questions 4. Medication event follow up Response Response CountCollect, identify themes, discuss on unit

12.5% 1

Collect, identify themes, no unit discussion

25.0% 2

Only address sentinel events, no unit discussion

12.5% 1

Collect, no unit discussion 12.5% 1

No collection, no follow up, no unit discussion

37.5% 3

Questions 5. Communication with QI on medication event infromation and trends

Response Response Count

Receive information 0.0% 0

No information 75.0% 6

Unknown 25.0% 2

Documents

IDENTIFYING MODIFIABLE BARRIERS IN THE ONLINE … · Web viewShe currently lives in Spofford, New Hampshire where she can enjoy everything the outdoors has to offer. Besides working