Quality Improvement:

Annet Jones, Christianne Madriaga, Nicole

Moreno, Enass Ramadan, Johanna Sotelo,
Marsha Tanare
GNRS 586
Background Information
Medical Errors are rampant within healthcare
Medication errors are the 3rd leading cause of
death, causing at least 250,000 deaths
10% of U.S. deaths are due to preventable medical
mistakes
In a 2-year study involving 11 hospitals, researchers
found that for every 20% decrease in staffing below
the staffing minimum, medication errors increased
by 18% (Duffin, 2014).
 Background
Nurse
Jane Thompson is a 37-year-old female

She has worked as a critical care registered nurse for almost 4 years
and has decided to go back to school to obtain her MSN degree

Jane Thompson is a full time student and worker now

She has never made a medication error prior to this event

Patient

John Williams is a 62-year-old male

Patient has history of MI, CHF, and CKD

Admitted to the intensive care unit following quadruple bypass heart

surgery
 Problems
Jane Thompson is working the night shift after having a
full day of classes
Jane is late on giving medications due to high activity on
the unit and was tending to family needs of her other
patient
Patient returns from surgery intubated so she decides to
crush the medications and administer them through his
nasogastric tube. She double checks for name and date
of birth, and scans her medications.
Jane crushes an extended-release calcium channel
blocker and administers via NG tube and accidentally
gives double the ordered dose
An hour later, J.W.s heart rate slows to asystole, and he
dies.
 Red Flags
Jane fails to notice the Do not crush warning on
the electronic medication administration record as
she rushed to administer her late meds

Jane fails to double check pulled medication and

gives the wrong dose

Inability to focus due to lack of sleep

Jane is distracted by family requests and high

activity on unit
Root Cause Analysis
Problem:

PLAN DO

PDSA

ACT STUDY
 PDSA: Aim
What are we trying to accomplish?

To improve the process of medication

management and administration and
reduce medication errors by 20% in the
intensive care units within 8 months.
 PDSA: Changes
What changes can we make that will result
in improvement?

A new protocol will be developed that

requires staff to verify the 6 rights of a
patient and document, as they are
performing the rights, on a checklist.
 PDSA: Plan
Tasks Person When Where
responsible

Create checklist to include 6 rights, make it Administration Within 1 week Administration

easy to print with information available in Office,
CCUs Medication
Room
Introduce, re-educate, and train nursing staff Nurse Within 3 weeks Staff meeting
regarding use of checklist and patients 6 rights Management of checklist room
(DON/Lead)
Prepare and dispense medication. Complete Pharmacists After completion Pharmacy/ Floor
checklist for each patient of training pharmacist

Administer medications. Complete checklist Nursing Staff After completion Patient room
for each patient for each medication of training

Investigate reports for incidents in medication Risk 8 months after

errors, violating 6 rights, and collect data on Management implementation
medication errors Team
 Checklist Example
Patient Name: John Williams
DOB: 07/04/54
Allergies: Penicillin
Medication Dose Time Route Doc Errors Complications

Carvedilol 20mg 0900 PO Y/N Y/N Patient is NPO. Pill comes

(Coreg) in capsule, unable to give
via NGT. Called pharmacy.

Chlorothiazide 500mg 0900 IV Y/N Y/N None

(Diuril)

Losartan 25mg 2100 PO Y/N Y/N Patient is NPO, pill is

(Cozaar) coated, crushed and
clogged NGT. Reported to
lead nurse

Nurse Name: Jane Thompson Nurse Signature:

Date:
 PDSA: Plan
Prediction Measures to determine if
prediction succeeds

Nurse Manager introduce, re-educate and train Sign in sheet at sessions in staff meeting rooms
90% of staff within 3 weeks

Pharmacists perform 6 rights for each patient Checklist turn in and completion. Any verbal
100% of the time, corrects and reports errors reporting

Staff Nurses perform 6 rights for each patient Checklist turn in and completion. Any verbal
using checklist 100% of the time, reports errors reporting

Risk Management Team identifies a 20% Data collected from checklist and document
reduction rate in medication errors in CCUs error types and complications
within 8 months
 PDSA: DO
Checklist protocol should take about 3-4 weeks to implement into
daily practice
Nurse managers/leads will observe for proper protocol and assess
completion of checklist
Directly work with nurses responsible for any errors
Assist with completion of checklist and retrain as needed
Update with recent policies
Pharmacist will turn in checklist at end of each shift to risk
management team members
Staff Nurses will report any errors to nurse managers/leads
Risk management team handles problems and unexpected
observations
Collect data and review/evaluate new protocol
 PDSA: Study
Prediction Outcome
Nurse Manager introduce, re-educate and 75% of staff goal reached at staff meetings
train 90% of staff within 3 weeks

Pharmacists perform 6 rights for each 85% of pharmacist goal reached. Review
patient 100% of the time, corrects and all medication errors and report those
reports errors related to overrides

Staff Nurses perform 6 rights for each 85% of staff nurse goal reached. Review all
patient using checklist 100% of the time, medication errors and report those
reports errors related to overrides

Risk Management Team identifies a 20% Risk Management Team documents 15%
reduction rate in medication errors in reduction rate in CCU med error types
CCUs and complications.
 PDSA: Study
Summary of findings:

The new protocol has been successful at

reducing the number of med errors in the CCU.
The goal of decreasing the number of med
errors by 30% was not attained; only 15%
reached.

The 3-4 week time frame may not have been

enough time to allow the staff to become
 PDSA: Act
Next steps what will you recommend as a
result of your small test of change?
CCU Nurse Manager notified of any
discrepancies in practice related to med
errors.

Continue to monitor for additional process

changes and implement as a result of med
errors overrides.
 Recommendations
Ensure the six rights of medication
administration are followed.
Follow proper medication reconciliation
procedures. (from unit to unit, hospital to
hospital)
Double check-or even triple check.
Have the physician or an prescriber read
back.
Consider using a name alert
 Recommendation Contd
Place a zero in front of the decimal point. A
dosage of 0.25 mg can easily be construed
as 25 mg without the zero in front of the
decimal point.
Document everything. This includes
labeling, legible documentation etc
Ensure proper storage of medications for
proper efficacy
if you made a med errors please report it
as soon as possible.
 Stakeholder Analysis
Internal (unit) stakeholders
Nurses
Doctors
pharmacists
Patients
Respiratory therapists.
External stakeholders.
Nursing homes
Patient family
Pharmaceutical companies.
Local pharmacies and pharmacists.
 Force Field Analysis
Forces FOR Forces AGAINST
Change Change
(Driving Forces) (Resisting Forces)
Implementing Time restraints on busy
Patient Safety the 6 rights of floors requiring efficient
nursing care
medication
administration Climate & Culture
Proper Medication
Administration for nurses

burn out, high nurse to

Improved Patient patient ratios
Outcomes

Multiple medications that

Financial incentives for need to be administered
nurses
 References
American Nurses Association. (2017). Safe staffing literature review. Retrieved from
http://nursingworld.org/SafeStaffing-LiteratureReview

American Nurses Today. (2017). Medication errors: Best practices. Retrieved from
https://www.americannursetoday.com/medication-errors-best-practices/

Dent, E.M. (2015). Improving patient safety: Reducing medication errors in the microsystem
(Masters thesis). Retrieved from http://repository.usfca.edu/cgi/viewcontent.cgi?article=
1115&context=capstone

Dexter, V. (2017). 10 strategies for preventing medication errors. Minority Nurse. Retrieved
from http://minoritynurse.com/10-strategies-for-preventing-medication-errors/

Duffin, C. (2014). Increase in nurse numbers linked to better patient survival rates in ICU.
Nursing Standard, 28(33),10. DOI: 10.7748/ns2014.04.28.33.10.s8.

Marquis, L. B and Huston, J. C (2015). Leadership Roles and Management Functions in Nursing.

Theory and Application. 8th Ed. Wolters Kluwer Health. Baltimore. USA.

United States News & World Report. (2016). Medical errors are the third leading cause of
death in the U.S. Retrieved from https://www.usnews.com/news/articles/2016-05-03/medical-errors-are-
third-leading-cause-of-death-in-the-us