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Search results for "Nurse Managers"

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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.

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 > 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

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

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 > 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

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

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.

Journal Article > Study

Medication-administration errors in an urban mental health hospital: a direct observation study.

Cottney A, Innes J. Int J Ment Health Nurs. 2015;24:65-74.

In this prospective observational study at a psychiatric hospital, errors were identified in 3% of medication administration episodes, with omission being the most common error type. As in prior studies, interruptions and higher patient volume were associated with increased risk of mistakes.

Journal Article > Study

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Journal Article > Study

Is there light? Well it depends—a grounded theory study of nurses, lighting, and medication administration.

Graves K, Symes L, Cesario SK, Malecha A. Nurs Forum. 2015;50:241-251.

This qualitative study found that bedside nurses frequently experienced difficulty with medication administration due to inadequate lighting in patient rooms. The effect of the physical environment on patient safety has been discussed in a previous PSNet perspective.

Journal Article > Commentary

Creating a distraction simulation for safe medication administration.

Thomas CM, McIntosh CE, Allen R. Clin Simul Nurs. 2014;10:406-411.

Nursing students and new registered nurses are more likely to make mistakes during medication administration due to lack of experience and insufficient knowledge. This commentary describes the development and implementation of a simulation program to help students experience the various interruptions and distractions that occur in the hospital environment while preparing medications to understand how they can contribute to errors and learn about risks associated with multitasking.

Journal Article > Review

Factors contributing to Registered Nurse medication administration error: a narrative review.

Parry AM, Barriball KL, While AE. Int J Nurs Stud. 2015;52:403-420.

The complexity of the care environment can hinder safe medication administration. This narrative review explores the evidence around nursing behaviors, individuals, and practice characteristics related to medication errors. As the studies identified focused primarily on environmental factors and few discussed how behaviors may contribute to adverse drug events, the authors advocate for further research into the relationship between medication administration behavior, care settings, and individuals when investigating errors.

Journal Article > Study

The occurrence of adverse events potentially attributable to nursing care in medical units: cross sectional record review.

D'Amour D, Dubois CA, Tchouaket É, Clarke S, Blais R. Int J Nurs Stud. 2014;51:882-891.

Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.

Journal Article > Study

Quiet please! Drug round tabards: are they effective and accepted? A mixed method study.

Verweij L, Smeulers M, Maaskant JM, Vermeulen H. J Nurs Scholarsh. 2014;46:340-348.

This study used direct observation and interviews to evaluate the effectiveness of tabards, do-not-disturb signs worn by registered nurses dispensing medications in inpatient settings, in preventing disruptions. The authors found a decrease in interruptions and medication errors, suggesting that tabards may augment safety despite controversy regarding their use.

Journal Article > Study

Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.

Tenhunen ML, Tanner EK, Dahlen R. J Contin Educ Nurs. 2014;45:306-311.

This quality improvement study found that an educational video designed to improve medication safety in nursing homes successfully enhanced nurses' knowledge about medication administration practices. A recent AHRQ WebM&M commentary discusses medication safety in nursing homes.

Journal Article > Study

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

Haw C, Stubbs J, Dickens GL. J Psychiatr Ment Health Nurs. 2014;21:797-805.

Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.

Journal Article > Study

Paediatric nurses' adherence to the double-checking process during medication administration in a children's hospital: an observational study.

Alsulami Z, Choonara I, Conroy S. J Adv Nurs. 2014;70:1404-1413.

On many hospital wards, standard policy calls for two nurses to double-check medications prior to administration, despite a lack of consistent evidence supporting this strategy. In this prospective observational study, pediatric nurses independently double-checked only 30% of drug administrations and adherence varied between weekdays and weekends.

Newspaper/Magazine Article

Audit of missed or delayed antimicrobial drugs.

Wright J. Nursing Times. 2013;109:11-14.

This record review study found that omitted doses of antimicrobial medications occur frequently in hospital settings in the United Kingdom.

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