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Search results for "Nurse Managers"

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Journal Article > Study

Examining the relationship among ambulatory surgical settings work environment, nurses' characteristics, and medication errors reporting.

Farag AA, Anthony MK. J Perianesth Nurs. 2015;30:492-503.

This survey study of nurses across four ambulatory surgical wards in Ohio found that nursing managers' leadership styles and some aspects of the safety climate (such as teamwork and organizational learning) were associated with how willing nurses are to report medication errors.

Journal Article > Study

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.

Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.

Press Release/Announcement

2007 Study of Injectable Medication Errors.

Silver Spring, MD: American Nurses Association; June 18, 2007.

The American Nurses Association announces the results from a survey of more than 1000 nurses on medication error and syringe safety.

Cases & Commentaries

Workaround Error

  • Web M&M

Tess Pape, PhD, RN, CNOR; February 2006

Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.

Journal Article > Commentary

Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes.

Effken JA, Brewer BB, Patil A, Lamb GS, Verran JA, Carley K. Int J Med Inform. 2005;74:605-613.

The authors describe their experience using a computerized model to understand the impact of organizational, patient unit, and patient characteristics on safety and quality. This study was supported with a grant from the Agency for Healthcare Research and Quality (AHRQ).

Journal Article > Study

Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?

Byrne C, Sierra H, Tolhurst R. Br J Nurs. 2017;26:464-467.

Checklists can improve patient safety across multiple settings. This pre–post study found that use of a checklist to help nurses dispense medications upon hospital discharge led to a reduction in errors in discharge prescriptions.

Journal Article > Study

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

Garcia BH, Elenjord R, Bjornstad C, Halvorsen KH, Hortemo S, Madsen S. BMJ Qual Saf. 2017 Apr 21; [Epub ahead of print].

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017 Feb 23; [Epub ahead of print].

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Commentary

Medication governance: preventing errors and promoting patient safety.

Kavanagh C. Br J Nurs. 2017;26:159-165.

Medication errors are a significant challenge to patient safety. Discussing various factors that weaken the medication administration process, this commentary highlights collaboration, safety culture, and curriculum development as tactics to enhance the role of nurses and nurse educators in improving medication safety.

Journal Article > Commentary

Teaching students to administer medications safely.

Koharchik L, Flavin PM. Am J Nurs. 2017;117:62-66.

Students are likely to make mistakes as they develop medication administration competencies. This commentary describes strategies to teach nursing students safe medication practices, including mathematical skill development and small group training.

Journal Article > Study

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. J Patient Saf. 2016 Dec 21; [Epub ahead of print].

Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.

Journal Article > Study

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Journal Article > Review

Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors.

Wolf ZR. J Infus Nurs. 2016;39:235-248.

Errors in administration of intravenous medications have potential to cause severe patient harm. This study analyzed medication administration errors voluntarily reported to the Institute for Safe Medication Practices. The investigator found that the most frequent error was excessive dosing and most errors were multifactorial, consistent with prior studies.

Journal Article > Study

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

Tong EY, Roman C, Mitra B, et al. J Clin Pharm Ther. 2016;41:414-418.

Medication discrepancies during hospital admission are common and can lead to preventable harm. This study examined the impact of having a pharmacist review medical charts of patients with complex medication regimens who were admitted to a general medical or emergency short-stay unit. The authors found that partnering medical staff with a pharmacist to review patients' admission medications in the chart significantly decreased inpatient medication errors.

Journal Article > Review

Is technology the best medicine? Three practice theoretical perspectives on medication administration technologies in nursing.

Boonen MJ, Vosman FJ, Niemeijer AR. Nurs Inq. 2016;23:121-127.

Technology solutions to enhance safety of medication administration have had mixed results, with unintended consequences diminishing initial enthusiasm for the tools. This review discusses how design and implementation of technology must consider nurses' knowledge, organizational context, and sensitivity to complexity to ensure that technologies augment safe nursing practice.

Journal Article > Study

Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: a retrospective observational study.

Elliott RA, Lee CY, Beanland C, Vakil K, Goeman D. Drugs Real World Outcomes. 2016;3:13-24.

Medication management is known to be especially high-risk for older adults. This study of older patients receiving home care services found polypharmacy, insufficient medication communication, and frequent errors in self-administration. These results emphasize the need to improve medication safety for older adults in community settings.

Journal Article > Study

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

Sears K, O'Brien-Pallas L, Stevens B, Murphy GT. J Pediatr Nurs. 2016;31:e283-e290.

This Canadian study found that nurses with more experience reported a greater number of pediatric medication administration errors, but these errors were less severe compared to other units. This finding suggests widespread underreporting of medication errors by nurses with a lower level of experience.

Journal Article > Study

Medication competency of nurses according to theoretical and drug calculation online exams: a descriptive correlational study.

Sneck S, Saarnio R, Isola A, Boigu R. Nurse Educ Today. 2016;36:195-201.

Nurses play a critical role in preventing medication errors. This study of registered nurses in Finland found that the vast majority had medication knowledge and drug calculation skills. Nurses in acute care units and those who were younger had better scores than nurses in other units and their older colleagues.

Newspaper/Magazine Article

Preventing medication errors by empowering patients.

Karch AM. Am Nurs Today. September 2015;10:18-22.

The complexity of care delivery can hinder the role of nurses in preventing medication errors. This commentary advocates for updating the five rights to consider the patient's role in their medication therapy and to incorporate patient and family education into the process to improve medication safety.

Journal Article > Study

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.

Keers RN, Williams SD, Cooke J, Ashcroft DM. BMJ Open. 2015;5:e005948.

The critical incident technique was used to identify active and latent errors that contributed to medication administration errors. The investigators found that high workload and lack of support led to nurses employing workarounds that increased the likelihood of error.

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