OPPORTUNITY

The Institute of Medicine’s (IOM) report To Err is Human: Building a Safer Health System shocked the healthcare community when it revealed a high level of medical –and more specifically— medication errors. One of five medication administrations was identified as contributing to over 400,000 serious injuries in hospitals and 48,000-98,000 medical related deaths per year. Each error was estimated to cost the hospital an average of $32.59-$155.80 in additional care for inpatient days, medication changes, and patient monitoring making Medication Errors (MEs) both a costly problem and serious quality of care issue. The IOM called for the problem to be critically evaluated and for changes to be made at the organizational level. Hospitals began trying to create a culture of safety and promoted the reporting of errors in order to better identify problems. As healthcare shifted away from the individual, systematic factors such as the organizations’ safety climate, poor working conditions, increased workload, shifts longer than 12.5 hours, and insufficient nursing staff were all identified as contributing to the creation of an environment that increased the probability of medication errors. Other clinical factors such as the number of patients being cared for and types of medications being administered to a patient, patient acuity, and number of tasks have all been shown to impact the clinical environment and Medication Administration Error (MAE) risk, but can fluctuate throughout the day on a single unit. However, healthcare staff has been reticent to recognize, admit to, or report MAEs due to reporter burden, professional identity, information gaps, organizational factors, and fear resulting in a significant gap between actual MAEs and reported MAEs. The promotion of electronic reporting, anonymous reporting, and the removal of punitive actions have all increased the reporting frequency of errors. Despite these changes there remains a persistent issue with clinical staff not reporting errors as they occur, requiring direct observation of the clinical environment necessary to identify additional factors that may contribute to MEs. Thus, identification of environmental stressors on a medical-surgical/telemetry floor in real-time and creation of a tool that would allow the nursing staff to identify when they are at risk for medication errors and how teamwork can assist in reducing the stressors experienced is essential to improve healthcare efficiency and patient safety.

BREAKTHROUGH IN RN MEDICATION ERROR RISK AWARENESS

Researchers at the University of South Alabama have created a tool that pulls real-time data from the clinical environment and hospital electronic health record, calculates the nurse’s risk based on historical threshold levels identified at the individual and unit level, and then displays the nurse’s risk for a medication error using a stoplight method. Using thresholds determined from historical data these researchers created a Nurse Risk Assessment (NRA) tool. The tool was then piloted on a Telemetry/Medical-Surgical unit for 30-days. Nurses in this study were instructed that the purpose of the tool was to make them more aware of high risk factors within their workload and to improve awareness, communication, and teamwork in reducing that risk. The Agency for Healthcare Research and Quality’s Patient Safety Survey (PSS) was used to measure perceived levels of peer, managerial, and organizational support as a baseline before the tool was implemented, and again upon the completion of the 30-day implementation of the NRA tool. Baseline and outcome levels for situational awareness resulting in Near-Misses were determined using the Bar-Code Medication Administration (BCMA). At the completion of this pilot the unit experienced a 15.6% reduction in Near-Misses as determined by the BCMA. The unit also reported a 10% improvement in the area of Teamwork and a Welch test found significant increase in the mean to the question dealing with respect for team members in the PSS.

COMPETITIVE ADVANTAGES

•  Uses real-time data to identify environmental stressors within a nursing environment

•  Notifies nursing staff when they are at risk for medication errors

•  Helps nursing staff identify solutions to reduce environmental stressors

•  Expands awareness of individual and peer workloads

•  Improves the perception of support given by peers and the manager

•  Increases healthcare efficiency while maximizing patient safety

INTELLECTUAL PROPERTY STATUS

Patented