| Principal Investigator: | Shelley B. Thibeau, RNC |
| Co-Principal Investigator/Collaborator: | Margaret T. Pizzitola |
| Organization: | Ochsner Health System |
Abstract
Problem
According to the Institute of Medicine, two out of every one hundred admissions experience a preventable adverse drug event. The pediatric population is especially vulnerable to medication errors due to variability in weight, lack of standardization of medication dilutions, and lack of awareness of medication safety practices. A comprehensive approach to improving medication safety in pediatric patients requires changes in organizational culture and medication administration practices.
Evidence
An electronic search of medication errors stored in a standardized occurrence reporting system was completed. Collected data included medication errors in the NICU categorized under the four processes: prescription, transcription, dispensing, and administration. Flow mapping of existing organizational practices identified system weaknesses in medication policies.
Strategy
Rapid cycles for improvement using the PDSA model were used to implement best practices identified during a two year Vermont Oxford Network collaborative.
Practice Change
Practice changes resulting from the project included: improving organizational safety culture, standardization of medication concentrations and revision in processes for prescribing and verifying medications.
Evaluation
Medication errors and “near misses” were identified over time using Run Charts to reflect impact of practice changes on overall error rates.
Results
A total of 11,753 patient days were used to determine results. Reporting of “near misses” increased from 0.7 to 21.91/1000 pt days. Medication errors reaching the patient decreased from baseline at peak of increased reporting from 5.27/1000pt days to 3.6/1000 pt days.
Recommendations
Lessons learned reiterate that organizational safety cultures are needed to increase awareness of the need for medication safety and can impact buy-in for needed practice changes. A multidisciplinary approach will ensure system changes adequately address organizational processes in medication delivery systems. The conclusions expressed are those of the authors and not necessarily those of the participants in the NIC/Q 2005 Collaborative or the Vermont Oxford Network.
Recognition
- 1st place poster winner, 2007 Summer Institute on Evidenced-Based Practice
Bibliography
- Deming, E. W. (1994). New Economics for Industry, Government, Education: MIT press.
- IOM, Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press.
- ISMP, Institute of Safe Medication Practices (2000). Hospital survey shows much more needs to be done to protect pediatric patients from medication errors [Electronic Version]. ISMP Safety Alert. Retrieved March 8, 2007 from http://www.ismp.org/Newsletters/acutecare/articles/20000419.asp.
- Kunac, D. L., Reith, D. M. (2005). Identification of priorities for medication safety in the neonatal intensive care. Drug Safety, 28(3), 251–261.
- VON, V. O. N. (2005-7). NICQ Project Meeting. Paper presented at the NICQ 2006 YANG, Philadelphia, Pennsylvania.