2.50
Hdl Handle:
http://hdl.handle.net/10755/164198
Category:
Abstract
Type:
Presentation
Title:
Using a Human Factors Process Analysis to Reduce Medication Error
Author(s):
Harder, Kathleen A.; Manchester, Carol S.
Author Details:
Kathleen A. Harder, PhD, University of Minnesota, Minneapolis, Minnesota, USA, email: nacnsorg@nacns.org; Carol S. Manchester, MSN, APRN, BC-ADM, CDE
Abstract:
Purpose: While medication errors have received extensive national attention in recent years, there is little definitive research to identify either what the probable causes of these errors are or the evidence-based interventions to eliminate them. The purpose of this research was to identify factors contributing to medication safety gaps in a complex acute care setting. Specific aims were to uncover systems flaws in order to identify deficiencies in the medication administration process that might lead to Significance: Evidence must be utilized to drive professional practice, develop safe and efficient medication administration processes, and promote clinical quality and patient safety. The CNS is key in evaluating systems and improving processes to reduce errors. Background/Design: This was a multi-phased exploratory qualitative research design. Methods: A Human Factors Process Analysis was used. It consisted of three phases: (1) analysis of medication error reports, (2) observation of work flow on three inpatient units, and (3) solicitation of insights through focus groups held with staff nurses. Each phase of the research informed subsequent phases. Findings: Key elements which could contribute to medication errors were identified in various systems and processes. These include the physical environment, leadership, education and competence, culture, and individual accountability. Conclusions: A significant strength of this research was the unique collaboration between CNSs and human factors researchers. A human factors perspective helped to identify critical issues contributing to errors and system flaws. This collaboration resulted in a synergistic analysis of workflow patterns and uncovered some difficulties nurses routinely encounter. Future systems should be designed to optimize professional performance while mitigating unsafe individual performance that occurs outside established parameters of practice. Implications for Practice: The researchers' utilized knowledge gained from this study to recommend systems improvements for the safety of administering medications. Immediate interventions that can be implemented to enhance patient safety are identified. Effective educational tools for nurses highlighting safety in the medication administration process will be developed. This study will also lead to future research utilizing simulated scenarios.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2007
Conference Name:
CNS Outcomes: Ensuring Safety and Quality
Conference Host:
NACNS - National Association of Clinical Nurse Specialists
Conference Location:
Phoenix, Arizona, USA
Description:
Conference theme: CNS Outcomes: Ensuring Safety and Quality, held February 28-March 1 in Phoenix, Arizona, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleUsing a Human Factors Process Analysis to Reduce Medication Erroren_GB
dc.contributor.authorHarder, Kathleen A.en_US
dc.contributor.authorManchester, Carol S.en_US
dc.author.detailsKathleen A. Harder, PhD, University of Minnesota, Minneapolis, Minnesota, USA, email: nacnsorg@nacns.org; Carol S. Manchester, MSN, APRN, BC-ADM, CDEen_US
dc.identifier.urihttp://hdl.handle.net/10755/164198-
dc.description.abstractPurpose: While medication errors have received extensive national attention in recent years, there is little definitive research to identify either what the probable causes of these errors are or the evidence-based interventions to eliminate them. The purpose of this research was to identify factors contributing to medication safety gaps in a complex acute care setting. Specific aims were to uncover systems flaws in order to identify deficiencies in the medication administration process that might lead to Significance: Evidence must be utilized to drive professional practice, develop safe and efficient medication administration processes, and promote clinical quality and patient safety. The CNS is key in evaluating systems and improving processes to reduce errors. Background/Design: This was a multi-phased exploratory qualitative research design. Methods: A Human Factors Process Analysis was used. It consisted of three phases: (1) analysis of medication error reports, (2) observation of work flow on three inpatient units, and (3) solicitation of insights through focus groups held with staff nurses. Each phase of the research informed subsequent phases. Findings: Key elements which could contribute to medication errors were identified in various systems and processes. These include the physical environment, leadership, education and competence, culture, and individual accountability. Conclusions: A significant strength of this research was the unique collaboration between CNSs and human factors researchers. A human factors perspective helped to identify critical issues contributing to errors and system flaws. This collaboration resulted in a synergistic analysis of workflow patterns and uncovered some difficulties nurses routinely encounter. Future systems should be designed to optimize professional performance while mitigating unsafe individual performance that occurs outside established parameters of practice. Implications for Practice: The researchers' utilized knowledge gained from this study to recommend systems improvements for the safety of administering medications. Immediate interventions that can be implemented to enhance patient safety are identified. Effective educational tools for nurses highlighting safety in the medication administration process will be developed. This study will also lead to future research utilizing simulated scenarios.en_GB
dc.date.available2011-10-27T11:43:51Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:43:51Z-
dc.conference.date2007en_US
dc.conference.nameCNS Outcomes: Ensuring Safety and Qualityen_US
dc.conference.hostNACNS - National Association of Clinical Nurse Specialistsen_US
dc.conference.locationPhoenix, Arizona, USAen_US
dc.descriptionConference theme: CNS Outcomes: Ensuring Safety and Quality, held February 28-March 1 in Phoenix, Arizona, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_US
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