Case Study: Using Electronic Medication Administration Record to Enhance Medication Safety and Improve Efficiency in Long-Term Care Facilities.

The electronic medication administration record (eMAR) has been used in hospitals and acute care facilities in Canada for over a decade. Unfortunately, the Canadian continuing care sector has been slow to adopt eMAR usage. Medication delivery in long-term care has traditionally been through paper-based orders and manual documentation in the paper medication administration record. The effectiveness of this manual system as it relates to medication incidents, patient safety and nursing efficiency is not well understood because most of the information is based on anecdotal evidence. Peer-reviewed scientific literature supports the premise that the eMAR, compared to the MAR, is more efficient, significantly reduces medication incidents, promotes patient safety and improves workflow efficiency. In April 2016, the Brenda Strafford Foundation committed to implementing the eMAR at each of our three long-term care facilities to improve medication delivery, reducing and eliminating medication incidents and evaluating the benefits of the electronic system. Under the direction of the clinical team, including nurses, physicians, pharmacists, and the software provider/vendor, an electronic system was developed and new processes for medication delivery were instituted within eight months of starting the project. Since the past year, the evaluation of the eMAR at the Brenda Strafford Foundation demonstrated a reduction in medication delivery time allowing for more time for direct care and a decrease in medication incidents, which directly affects resident health and safety. Nursing and the healthcare aides trained in medication management were surveyed and indicated that the eMAR provides a holistic view of the resident and provides important information readily available to improve the quality of resident care.

MedManage: The development of a tool to assist medication reconciliation in a rural primary care clinic.

BACKGROUND: Medication reconciliation is a critical step in the health care process to prevent hospital readmission, adverse drug events, and fall prevention. The purpose of the study was to pilot test a medication reconciliation process, MedManage, informed by the Medications at Transitions and Clinical Handoffs (MATCH) toolkit with nursing staff in a rural primary care clinic. METHODS: The research team conducted 38 chart audits of high-risk patients, and preintervention and postintervention were conducted to assess changes in medications reported by patients. The intervention included a chart audit tool and medication reconciliation tool created by the interdisciplinary team, MedManage, were pilot tested in the clinic. CONCLUSIONS: The Use of MedManage resulted in improvements in patient reporting of over-the-counter (82% of patients reported previously unrecorded OTCs), PRN medications (3% unreported), and herbal supplements/vitamins (28% reported previously unrecorded vitamins). IMPLICATIONS FOR PRACTICE: MedManage may be an effective tool to assist clinical nursing staff to attain a more complete and accurate medication list from patients and should be assessed more broadly across rural primary care clinics.

Calm to chaos: Engaging undergraduate nursing students with the complex nature of interruptions during medication administration.

AIMS AND OBJECTIVES: To describe undergraduate student nurse responses to a simulated role-play experience focussing on managing interruptions during medication administration. BACKGROUND: Improving patient safety requires that we find creative and innovative methods of teaching medication administration to undergraduate nurses in real-world conditions. Nurses are responsible for the majority of medication administrations in health care. Incidents and errors associated with medications are a significant patient safety issue and often occur as a result of interruptions. Undergraduate nursing students are generally taught medication administration skills in a calm and uninterrupted simulated environment. However, in the clinical environment medication administration is challenged by multiple interruptions. DESIGN/METHODS: A qualitative study using convenience sampling was used to examine student perceptions of a simulated role-play experience. Data were collected from 451 of a possible 528 student written reflective responses and subject to thematic analysis. RESULTS: Students reported an increased understanding of the impacts of interruptions while administering medications and an improved awareness of how to manage disruptions. This study reports on one of three emergent themes: "Calm to chaos: engaging with the complex nature of clinical practice." CONCLUSIONS: Interrupting medication administration in realistic and safe settings facilitates awareness, allows for students to begin to develop management strategies in relation to interruption and increases their confidence. Students were given the opportunity to consolidate and integrate prior and new knowledge and skills through this role-play simulation.

Errores en la preparación y administración de medicamentos: una revisión integradora de la Literatura Latinoamericana / Errors in the preparation and administration of medications: an integrative review of Latin American literature

Objetivo: Analizar, respecto su contenido, la producción científica de enfermeros latinoamericanos sobre error en la preparación y administración de medicamentos entre el año 2005 al 2011, en las bases de datos Centro Latinoamericano y del Caribe de Información en Ciencias de la Salud (LILACS) y Biblioteca Electrónica Científica (SciELO). Metodología: Consistió en una revisión integradora. La recolección fue realizada en el mes de Octubre de 2012 y de acuerdo a los criterios de inclusión, fueron seleccionados ocho artículos. Resultados: Los artículos fueron analizados en cuanto a los objetivos, trayectoria metodológica, principales resultados y propuestas de mejora. El análisis señala producción exclusiva de Brasil, estudios descriptivos, realizados en hospitales y con sugerencias generales como educación continua, notificación de los errores, implementación de una cultura de seguridad. Conclusiones: Considerando los aspectos enfatizados por la Organización Mundial de Salud (OMS) para alcanzar una atención más segura: buscar causas, proponer soluciones y evaluar impacto, se concluye que la producción necesita conocimiento que efectivamente mejore la práctica. Impulsar la investigación analítica con la mirada al sistema permitirá el desarrollo de propuestas efectivas y de acorde a la realidad (AU)

Objective: To analyze the contents the scientific production of Latin American nurses regarding on preparation and administration of medical drugs from 2005 to 2011 using Latin American and Caribbean Center Information the Health Sciences (LILACS) y Electronics Scientific Library (SciELO) databases. Methodology: The following research was an integrative review. Data collection was performed in the month of October 2012 and according to the inclusion criteria, were selected eight articles. Results: The articles were analyzed in terms of objectives, methodological path, main results and suggestions for improvement. The analysis indicates exclusive production of Brazil, descriptive studies, conducted in hospitals and general suggestions as continuing education, error reporting and implementation of a safety culture. Conclusions: Considering that aspects emphasized by the World Health Organization (OMS) to achieve safer care are: to find causes, to propose solutions and to evaluate the impact, it is concluded that production need of knowledge that effectively improve professional practice. Looking to the system, promoting researches with analytical studies will allow effective responses according to reality (AU)

A multi-disciplinary approach to medication safety and the implication for nursing education and practice.

BACKGROUND: Medication management is a complex multi-stage and multi-disciplinary process, involving doctors, pharmacists, nurses and patients. Errors can occur at any stage from prescribing, dispensing and administering, to recording and reporting. There are a number of safety mechanisms built into the medication management system and it is recognised that nurses are the final stage of defence. However, medication error still remains a major challenge to patient safety globally. OBJECTIVES: This paper aims to illustrate two main aspects of medication safety practices that have been elicited from an action research study in a Scottish Health Board and three local Higher Education Institutions: firstly current medication safety practices in two clinical settings; and secondly pre and post-registration nursing education and teaching on medication safety. METHOD: This paper is based on Phase One and Two of an Action Research project. An ethnography-style observational method, influenced by an Appreciative Inquiry (AI) approach was adapted to study the everyday medication management systems and practices of two hospital wards. This was supplemented by seven in-depth interviews with nursing staff, numerous informal discussions with healthcare professionals, two focus-groups, one peer-interview and two in-depth individual interviews with final year nursing students from three Higher Education Institutions in Scotland. RESULT: This paper highlights the current positive practical efforts in medication safety practices in the chosen clinical areas. Nursing staff do employ the traditional 'five right' principles - right patient, right medication, right dose, right route and right time - for safe administration. Nursing students are taught these principles in their pre-registration nursing education. However, there are some other challenges remaining: these include the establishment of a complete medication history (reconciliation) when patients come to hospital, the provision of an in-depth training in pharmacological knowledge to junior nursing staff and pre-registration nursing students. CONCLUSION: This paper argues that the 'five rights' principle during medication administration is not enough for holistic medication safety and explains two reasons why there is a need for strengthened multi-disciplinary team-work to achieve greater patient safety. To accomplish this, nurses need to have sufficient knowledge of pharmacology and medication safety issues. These findings have important educational implications and point to the requirement for the incorporation of medication management and pharmacology in to the teaching curriculum for nursing students. There is also a call for continuing professional development opportunities for nurses working in clinical settings.

The relationship between simulation in nursing education and medication safety.

This experimental study examined whether the use of clinical simulation in nursing education could help reduce medication errors. Fifty-four student volunteers were randomly assigned to an experimental (treatment) group (24 students) or a clinical control group (30 students). The treatment replaced some early-term clinical placement hours with a simulated clinical experience. The control group had all normally scheduled clinical hours. Treatment occurred prior to opportunities for medication administration.

Clinical faculty development: using simulation to demonstrate and practice clinical teaching.

Students spend more time in clinical settings with smaller student-to-faculty learning ratios than in the didactic setting, yet many clinical faculty have had little exposure to evidence-based teaching strategies and learning theories. Orientation for newly employed clinical faculty, whether novices or experienced teachers, typically focuses on the details of running the clinical experience and not on teaching and learning. Multiple barriers for clinical faculty limit the ability to provide consistent and comprehensive education. The purpose of this article is to share the use of simulation as a strategy to prepare and support clinical faculty in their teaching role.

A criminal trial simulation: pathway to transformative learning.

Simulation is gaining popularity as an instructional method in education. The authors describe the simulation of a criminal trial stemming from a medication error. The simulation took place as a collaborative effort between undergraduate and graduate faculty teaching an issues and trends course. Bradshaw's model of transformative learning was used to design the simulation. Graduate students role played the individuals involved in the trial, and the undergraduate students acted as jurors. The curriculum design, the preparation, and the debriefing process are discussed. Lessons learned and suggestions for future simulated learning experiences are provided.

An exploratory mixed-methods study of Scottish midwives' understandings and perceptions of clinical near misses in maternity care.

OBJECTIVE: adverse outcomes and near misses are believed to share many characteristics in terms of clinical situations and care management problems. Little is documented concerning what prevents adverse outcomes from happening once the 'accident trajectory' begins. This two-stage pilot study set out to investigate midwives' understandings and recollections of clinical near misses. DESIGN: anonymous self-completion questionnaire and follow-up group interviews. SETTING/PARTICIPANTS: clinically based midwives working in four maternity units in Scotland (questionnaire [n = 34]; interviews [n = 26]). FINDINGS: despite a low response rate to the questionnaire, the cited examples seem to confirm that near misses and adverse outcomes follow essentially similar routes until the former are halted by a saving intervention. Dangerous situations are created by heavy workloads, and are aggravated by sub-optimal skill-mix, poor communication and individuals making mistakes or not following accepted procedures. Overwhelmingly, what prevents this situation from resulting in an adverse outcome is an intervention by another practitioner--often reported to be by chance and not design. In the interviews, these situations were discussed with reference to unit culture, the causes of errors and near misses, helping to prevent mistakes, the consequences of near misses and staff confiding in one another. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: this limited study reaffirms the view that clinical near misses have the same origins as actual poor outcomes. Practitioners need to be able to discuss clinical and operational matters openly with colleagues. Although the 'blame culture' was reported to be less prevalent when things go wrong, not all midwives feel comfortable about discussing incidents or near misses. This exploratory study makes no claim to encapsulate this complex and sensitive subject. Further detailed research into the nature and extent of near misses is required. Identifying what prevents a poor outcome from happening may be a valuable clinical resource.