The Alphabet Soup of Med Errors from A to I --How to Collaborate to Decrease Errors

2.50
Hdl Handle:
http://hdl.handle.net/10755/307955
Category:
Abstract
Type:
Presentation
Title:
The Alphabet Soup of Med Errors from A to I --How to Collaborate to Decrease Errors
Author(s):
Rita, Bush; Pietryga, Glenda; Janssen, Jane
Lead Author STTI Affiliation:
Non-member
Author Details:
Bush Rita, MSN, BSN, CCRN, NE-BC, rbushrn@aol.com; Glenda Pietryga, PharmD; Jane Janssen, BSN, MBA
Abstract:

Poster presented on: Saturday, November 16, 2013, Sunday, November 17, 2013

Medication errors are multifaceted and can happen at any point in the preparation and delivery process. The Institute of Medicine (IOM) 2006 Report Preventing Medication Errors highlighted that 380,000 preventable adverse drug events take place each year in hospitals.  Weekly Medication Error Meetings that nursing and pharmacy managers attend assist in decreasing the errors that reach the patient and help with identifying institution system process changes. Managers receive information regarding each medication error via the online incident reporting system. Managers review the error, educate staff, remediate staff, and look for system opportunities with 48 hours of receiving the report. Each Friday the CNO leads the nursing/pharmacy leadership group in a discussion of lessons learned from reports and looks for system opportunities for improvement.  Managers in attendance give three pieces of information  to assist in looking for trends: 1. How long has the staff member been a nurse/pharmacist 2.  How many hours into their shift did the error occur 3. How many shifts in a row have they worked. Two system changes thus far have occurred from trends identified.  Pharmacists’ hours were decreased to 8 hour shifts. New graduate nurses no longer allowed to “override” any medication without a co-sign from a Registered Nurse to provide for education and patient safety. Overall the percentage of system medication errors reported decreased 15% from 2011-2012-those with a severity code of C-F decreased from 85% to 81%-near misses reported or category A-B reports increased from 14%-18%. Collaborating with a multidisciplinary team that meets weekly has improved our A-I error reporting process and assisted us to more quickly identify and make needed system changes.
Keywords:
collaboration; medication error
Repository Posting Date:
19-Dec-2013
Date of Publication:
19-Dec-2013
Conference Date:
2013
Conference Name:
42nd Biennial Convention
Conference Host:
Sigma Theta Tau International, the Honor Society of Nursing
Conference Location:
Indianapolis, Indiana, USA
Description:
42nd Biennial Convention 2013 Theme: Give Back to Move Forward. Held at the JW Marriott
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.

Full metadata record

DC FieldValue Language
dc.language.isoen_USen_GB
dc.type.categoryAbstracten_GB
dc.typePresentationen_GB
dc.titleThe Alphabet Soup of Med Errors from A to I --How to Collaborate to Decrease Errorsen_GB
dc.contributor.authorRita, Bushen_GB
dc.contributor.authorPietryga, Glendaen_GB
dc.contributor.authorJanssen, Janeen_GB
dc.contributor.departmentNon-memberen_GB
dc.author.detailsBush Rita, MSN, BSN, CCRN, NE-BC, rbushrn@aol.com; Glenda Pietryga, PharmD; Jane Janssen, BSN, MBAen_GB
dc.identifier.urihttp://hdl.handle.net/10755/307955-
dc.description.abstract<p>Poster presented on: Saturday, November 16, 2013, Sunday, November 17, 2013</p>Medication errors are multifaceted and can happen at any point in the preparation and delivery process. The Institute of Medicine (IOM) 2006 Report Preventing Medication Errors highlighted that 380,000 preventable adverse drug events take place each year in hospitals.  Weekly Medication Error Meetings that nursing and pharmacy managers attend assist in decreasing the errors that reach the patient and help with identifying institution system process changes. Managers receive information regarding each medication error via the online incident reporting system. Managers review the error, educate staff, remediate staff, and look for system opportunities with 48 hours of receiving the report. Each Friday the CNO leads the nursing/pharmacy leadership group in a discussion of lessons learned from reports and looks for system opportunities for improvement.  Managers in attendance give three pieces of information  to assist in looking for trends: 1. How long has the staff member been a nurse/pharmacist 2.  How many hours into their shift did the error occur 3. How many shifts in a row have they worked. Two system changes thus far have occurred from trends identified.  Pharmacists’ hours were decreased to 8 hour shifts. New graduate nurses no longer allowed to “override” any medication without a co-sign from a Registered Nurse to provide for education and patient safety. Overall the percentage of system medication errors reported decreased 15% from 2011-2012-those with a severity code of C-F decreased from 85% to 81%-near misses reported or category A-B reports increased from 14%-18%. Collaborating with a multidisciplinary team that meets weekly has improved our A-I error reporting process and assisted us to more quickly identify and make needed system changes.en_GB
dc.subjectcollaborationen_GB
dc.subjectmedication erroren_GB
dc.date.available2013-12-19T17:24:38Z-
dc.date.issued2013-12-19-
dc.date.accessioned2013-12-19T17:24:38Z-
dc.conference.date2013en_GB
dc.conference.name42nd Biennial Conventionen_GB
dc.conference.hostSigma Theta Tau International, the Honor Society of Nursingen_GB
dc.conference.locationIndianapolis, Indiana, USAen_GB
dc.description42nd Biennial Convention 2013 Theme: Give Back to Move Forward. Held at the JW Marriotten_GB
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.en_GB
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