2.50
Hdl Handle:
http://hdl.handle.net/10755/182179
Category:
Abstract
Type:
Presentation
Title:
Addressing Medication Errors: A Good Catch Initiative for Near Misses
Author(s):
Henderson, Terri
Author Details:
Terri Henderson, RN, BSN, Department Director, Children's Health System, Birmingham, Alabama, USA, email: terri.henderson@chsys.org
Abstract:
Poster presentation, ANCC National Magnet Conference: Health care facilities have a responsibility to assure all patients receive safe and effective care. In April 2008, a team of acute care inpatient pediatric nurses was developed to investigate the surge of medication errors occurring on the unit. They decided to explore and identify factors to any underlying causes and possible solutions to prevent medication errors. Medication errors were gathered from an online occurrence reporting system (OOPs) during a 3 year time frame (2006-2008). The goal of this project was to decrease medication errors by 50% and prevent all never events. Data analysis revealed, RN administration of the incorrect dose of medication was the most common medication error made. The most common level of error was category B (classified as an error occurred but did not reach the patient). This level is considered near misses. Consequently, a good catch campaign began. Nurses completed a near miss form on all disciplines as well as themselves when a near miss occurred. Monthly recognition occurred to the nurses with good catches. By the end of 2008, medication errors had decreased 76%. Results from a survey conducted to the nurses revealed the near miss form helped them to be more aware of the potential error. The combined strategy of near misses (expectations), acknowledgement of RN good catches, unit display (reward), and involvement in writing more detailed OOPs reports (meaningful contributions), is believed to have collectively prevented medication errors and provided clinical evidence of improved medication administration.
Repository Posting Date:
28-Oct-2011
Date of Publication:
28-Oct-2011
Conference Date:
2010
Conference Name:
ANCC National Magnet Conference
Conference Host:
American Nurses Credentialing Center
Conference Location:
Phoenix, Arizona, USA
Description:
The 14th American Nurses Credentialing Center (ANCC) National Magnet Conference, held 13-15 October, 2010 at the Phoenix Convention Center 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.titleAddressing Medication Errors: A Good Catch Initiative for Near Missesen_GB
dc.contributor.authorHenderson, Terrien_US
dc.author.detailsTerri Henderson, RN, BSN, Department Director, Children's Health System, Birmingham, Alabama, USA, email: terri.henderson@chsys.orgen_US
dc.identifier.urihttp://hdl.handle.net/10755/182179-
dc.description.abstractPoster presentation, ANCC National Magnet Conference: Health care facilities have a responsibility to assure all patients receive safe and effective care. In April 2008, a team of acute care inpatient pediatric nurses was developed to investigate the surge of medication errors occurring on the unit. They decided to explore and identify factors to any underlying causes and possible solutions to prevent medication errors. Medication errors were gathered from an online occurrence reporting system (OOPs) during a 3 year time frame (2006-2008). The goal of this project was to decrease medication errors by 50% and prevent all never events. Data analysis revealed, RN administration of the incorrect dose of medication was the most common medication error made. The most common level of error was category B (classified as an error occurred but did not reach the patient). This level is considered near misses. Consequently, a good catch campaign began. Nurses completed a near miss form on all disciplines as well as themselves when a near miss occurred. Monthly recognition occurred to the nurses with good catches. By the end of 2008, medication errors had decreased 76%. Results from a survey conducted to the nurses revealed the near miss form helped them to be more aware of the potential error. The combined strategy of near misses (expectations), acknowledgement of RN good catches, unit display (reward), and involvement in writing more detailed OOPs reports (meaningful contributions), is believed to have collectively prevented medication errors and provided clinical evidence of improved medication administration.en_GB
dc.date.available2011-10-28T15:12:41Z-
dc.date.issued2011-10-28en_GB
dc.date.accessioned2011-10-28T15:12:41Z-
dc.conference.date2010en_US
dc.conference.nameANCC National Magnet Conferenceen_US
dc.conference.hostAmerican Nurses Credentialing Centeren_US
dc.conference.locationPhoenix, Arizona, USAen_US
dc.descriptionThe 14th American Nurses Credentialing Center (ANCC) National Magnet Conference, held 13-15 October, 2010 at the Phoenix Convention Center in Phoenix, Arizona, USA.en_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.-
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