Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units. Issue 5 (September 2017)

• Record Type: Journal Article
• Authors: Xu, Jie; Reale, Carrie; Slagle, Jason M.; Anders, Shilo; Shotwell, Matthew S.; Dresselhaus, Timothy; Weinger, Matthew B.
• Is Part Of: Nursing research. Volume 66:Issue 5(2017)
• Publication Date: 2017-09
• Subjects: intensive care -- medication errors -- nursing -- voluntary patient safety event reporting -- workload; Nursing -- Research -- Periodicals; Nursing -- Periodicals; Nursing -- Periodicals; Soins infirmiers -- Recherche -- Périodiques; Soins infirmiers -- Périodiques; Verpleegkunde; Nursing; Nursing -- Research; Periodicals; 610.73
• DOI: 10.1097/NNR.0000000000000240
• Languages: English
• ISSNs: 0029-6562

Abstract

Abstract : Background: Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management—especially medication-related events (MREs)—provides an approach to analyze and improve medication safety and quality. Objectives: The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs. Methods: We conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts. Results: MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts. Discussion: Most of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.