Quantitative1-StaffEducationalProgramtoPreventMedicationErrors.pdf

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2018

Staff Educational Program to Prevent Medication
Errors
Rita Chinyere Hawthorne-Kanife
Walden University

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Walden University

College of Health Sciences

This is to certify that the doctoral study by

Rita Chinyere Hawthorne-Kanife

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by

the review committee have been made.

Review Committee

Dr. Janice Long, Committee Chairperson, Faculty

Dr. Anita Williams Manns, Committee Member, Faculty

Dr. Mary Martin, University Reviewer, Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

Walden University

2018

Abstract

Staff Educational Program to Prevent Medication Errors

by

Rita Hawthorne-Kanife

BSN, Prairie View A & M University, 2003

MSN/MSHA, University of Phoenix, 2008

FNP Post Graduate Certificate, South University, 2017

Project Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Practice

Walden University

August 2018

Abstract

Medication administration errors (MAEs) may lead to adverse drug events, patient

morbidity, prolonged hospital stays, and increased readmission rates, and may contribute

to major financial losses for the health system. MAEs are the most common type of error

occurring within the health care setting leading to an estimated 7,000 patient deaths every

year. Interventions have been designed to prevent MAEs including education for nurses

who administer medications; however, little effort has been made to design systematic

educational programs that are based on local needs and contexts. The purpose of this

project was to identify internal and external factors related to MAEs at the practice site,

develop an education program tailored to the factors contributing to MAEs, and

implement the program using a pretest posttest design. The Iowa model was used to

guide the project. The 26 nurse participants who responded to an initial survey indicated

that nurses felt distractions and interruptions during medication administration, and

hesitancy to ask for help or to report medication errors increased MAE risks. After the

education program, the pretest and posttest results were analyzed and revealed

improvement in knowledge and confidence of medication administration (M = 3.2 pre, M

= 3.7 post, p < .05). Open-ended question responses suggested a need for dedicated time for preparation and administration of medications without interruptions. Positive social change is possible as nurses become knowledgeable and confident about medication administration safety and as patients are protected from injury secondary to MAEs. Staff Educational Program to Prevent Medication Errors by Rita Hawthorne-Kanife BSN, Prairie View A & M University, 2003 MSN/MSHA, University of Phoenix, 2008 FNP Post Graduate Certificate, South University, 2017 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Practice Walden University August 2018 Dedication To the memory of my beloved and wonderful parents - Gilbert Okpomeshine Nzeocha and Theresa Omongu Nzeocha. Your exceptional guidance, inspiration and motivation will forever be cherished. To my sweet, affectionate, and caring husband, John Chidi Kanife Jr., and my dear children. Words are insufficient to express my gratitude for your unparalleled love, support, and sacrifice during this Doctoral program. You were the force that kept me sailing. And, to Almighty God who gave me the strength and tenacity to “soldier on” and complete this academic program, thank you. Acknowledgments I would like to express my profound gratitude to the people who have supported and encouraged me in this academic pursuit. I owe a debt of thanks to my Project Supervisors Dr. Oscar Lee, Dr. Janice Long, and Dr. Anita Manns for their insight, timely feedback, and constructive critique. It has been rewarding to learn from sterling scholars like Dr. Nancy Moss, at Walden University. Thanks also to Dr. Cozart Huberta, and to Dr. Nicholas Masozera. Similarly, my gratitude also goes to all of my clinical preceptors Molly Paul, NP, Simon Omana, NP, Dr. Uchenna Nworah, NP, Chidi Obinani, NP, Agnes Anyalebechi, NP, Freda Ekpa, NP, Dr. Ifeyinwa Onwudiwe, Alvin Mena Cantero, NP, and my unit manager Althea Phillips-Edwards. I will use the cumulative knowledge gained from your preceptorship for the greater good of humankind. I must not fail to mention my "heaven- sent" husband, John Chidi Kanife Jr., for his sacrifice and support during this academic journey. I wonder who would have better taken care of the children and the home front if you were not present. i Table of Contents List of Tables ..................................................................................................................... iv List of Figures ......................................................................................................................v Section 1: Overview of the Project ......................................................................................1 Introduction ....................................................................................................................1 Problem Statement .........................................................................................................2 Significance to the Field of Practice ................................................................3 Purpose ...........................................................................................................................4 Nature of Doctoral Project .............................................................................................5 Significance....................................................................................................................7 Contribution to Practice ...................................................................................7 Transferability of the Doctoral Project ..........................................................................8 Positive Social Change ..................................................................................................8 Summary ........................................................................................................................9 Section 2: Background and Context ..................................................................................11 Introduction ..................................................................................................................11 Concepts, Models, and Theories ..................................................................................12 Relevance to Practice .....................................................................................18 Local Background and Context ...................................................................................22 Role of the DNP Student..............................................................................................22 Summary ......................................................................................................................23 Section 3: Collection and Analysis of Evidence ................................................................25 ii Introduction ..................................................................................................................25 Practice-Focused Question...........................................................................................25 Sources of Evidence .....................................................................................................26 Evidence Generated for the DNP Project ....................................................................26 Procedures ....................................................................................................................27 Protections....................................................................................................................28 Analysis and Synthesis ................................................................................................28 Summary ......................................................................................................................29 Section 4: Findings and Recommendations .......................................................................30 Introduction ..................................................................................................................30 Findings and Implications ............................................................................................30 Difficulties and Obstacles When Administering Drugs...............................................30 Designing an Appropriate Educational Intervention for Nurses ..................................32 Educational Intervention Effectiveness Assessment ...................................................35 Explanation of Table 1 .................................................................................................37 Recommendations ........................................................................................................38 Project Strengths and Limitations ................................................................................39 Section 5: Dissemination Plan ...........................................................................................41 Dissemination Plan ......................................................................................................41 Analysis of Self ............................................................................................................41 Summary ......................................................................................................................42 References ..........................................................................................................................44 iii Appendix A: Self-Administered Medication Administration Safety Survey ....................50 Appendix B: Search Matrix ..............................................................................51 Appendix C: Staff Education Program ..............................................................................52 iv List of Tables Table 1. Comparison of the Nurses` KSAs ........................................................................36 v List of Figures Figure 1. Iowa Model: Framework for the Project .......................................................... 16 1 Section 1: Overview of the Project Introduction Medication errors are a common phenomenon within hospital and clinical settings. Medication errors may lead to various adverse drug events, increased readmission rates, and prolonged patient stays in the hospital (Berdot et al., 2016; Blignaut, Coetzee, Klopper, & Ellis, 2017; Vrbnjak, Denieffe, O’Gorman, & Pajnkihar, 2016). The medication process consists of three main stages (prescription, delivery, and administration). All three stages are prone to human error (Dubovi, Levy, & Dagan, 2017; Strickler et al., 2016; Vrbnjak et al., 2016). However, it is essential to highlight the prevalence of medication errors occurring at the administration stage (over 33% of the cases) and is the least researched within evidence-based literature (Berdot et al., 2016). One of the most important functions for which registered nurses (RNs) are responsible is the administration of medication (Booth, Sinclair, Brennan, & Strudwick, 2017). By definition, medication administration errors (MAEs) are deviations from the provided medication order (Berdot et al., 2016). Reducing the number of errors associated with medication administration has become an important issue when improving nurse service quality (Vrbnjak et al., 2016). In fact, MAEs are the most common type of errors occurring within the healthcare setting, which annually lead to an estimated 7,000 patient deaths every year (Gonzales, 2010). At the same time, as pointed out by Blignaut et al. (2017), new RNs commonly reported inadequate training and educational preparation for safe medication administration. New RNs are particularly vulnerable to medication errors (Dubovi et al., 2 2017). There is a need for evidence-based practice applications to identify effective teaching interventions that can help nurses develop the skills required to meet the challenges of the clinical workplace (Dubovi et al., 2017; Gonzales, 2010; Strickler et al., 2016). Finally, traditional methods to educate nurses about medication administration safety remain a core technique used to address medication administration safety (Härkänen, Voutilainen, Turunen, & Vehviläinen-Julkunen, 2016). Nurse educators should consider developing holistic and comprehensive tools that can provide nurses with the necessary knowledge, experience, and attitudes needed to minimize incidences of medication administration-related errors (Gonzales, 2010). The aim of my Doctor of Practice (DNP) project was to develop an educational program for staff nurses that would help them understand issues related to MAEs, error-reporting approaches, and possible individual and organization-wide techniques. These techniques help to mitigate errors. My project showed it was possible to improve outcomes that would lead to positive social change among nurses and practitioners. The expected measurable project outcome included the results of a pretest and a posttest. The results demonstrated that training increased nurses` knowledge concerning medication administration, error sources, and prevention techniques. Problem Statement MAEs are the most common types of errors occurring within the healthcare setting. These errors annually lead to an estimated 7,000 patient deaths every year (Gonzales, 2010). Hospitals are actively implementing organization-wide interventions targeting reduction of MAEs to reduce this threat to patient safety in the health system. 3 Developing and delivering an education program based on the most recent evidence for preventing medication errors is an effective method to reduce MAEs (Vrbnjak et al., 2016). New RNs commonly report inadequate training and educational preparation for safe medication administration (Blignaut et al., 2017). Consequently, it is important to identify ways to address the problem. While education programs are not new to nursing, there is a need to provide education as often as necessary. It is necessary to document that nurses understand how to implement what they have been taught. In the clinical setting where intervention took place, it was important to get the information out to nurses in such a way that they understood the need to adhere to specific protocols of medication administration and error prevention. Significance to the Field of Practice The interventions included providing staff nurses and nurse practitioners with the necessary knowledge to provide safe medication administration to their patients. The outcome was achieved by developing and using a comprehensive and ready-to-apply educational program for nurses working in a clinical healthcare setting. It was important to highlight that the educational program developed could be applied not only to new nurses. The program could also be useful for RNs who are actively engaged in practical work. The latter group can benefit from improving their current level of education about drug administration safety and help develop a necessary level of self-esteem needed for effective professional performance in a challenging environment, such as nurse practice (Mettiäinen, Luojus, Salminen, & Koivula, 2014). 4 Purpose The purpose of my project was to identify internal and external factors most relevant to nurse medication administration errors at the clinical practice site and to develop and provide an educational program for nurses. In the clinic setting, where the intervention took place, there was no comprehensive educational program for the nursing staff to improve the quality of medication administration and reduce associated errors. Continuing education for nurses can help address the gaps currently existing in nursing practice settings (Booth et al., 2017). Continuing education can assist with the development of an effective focus on service quality and patient safety. Project guidance relied on the following practice-focused question: Does an evidence-based practice education program on medication administration safety and error prevention improve a nurse’s knowledge of medication safety and error prevention? The question highlights an information gap that was addressed through the review of the literature which provided evidence that holistic and systematic education-based efforts promote safe medication administration among nursing staff. This can help to improve the performance of RNs, and as a result—patient health outcomes (Berdot et al., 2016; Booth et al., 2017; Dubovi et al., 2017). In fact, the latter is rarely implemented within the context of healthcare organizations (Mettiäinen et al., 2014). The implemented measures are often reactive in nature (addressed specific incidents as opposed to being directed to prevent future ones). These measures focus on a single component of nursing practice (e.g., calculations, medication preparation) (Gonzales, 5 2010; Mettiäinen et al., 2014). In addition, these sporadic methods are not tailored to the specific needs of a healthcare institution in focus, but rather concern general practices and techniques of medication administration (Mettiäinen et al., 2014). My project bridged the identified gap in the following way. Through review of the literature, the project question helped to identify risk factors that would negatively affect medication administration safety. The project’s question was provided guidance for literature review, the development of an evidence- based practice, comprehensive educational program for nurses, and the corresponding pre and post test used in the project. Nature of Doctoral Project My doctoral project was an evidence-based learning intervention based on published evidence about medication administration safety and error prevention. The information was the basis for developing an education program for a specific clinical setting. I used the Iowa Model to develop the education program. The Iowa Model is an appropriate framework to help identify effective educational interventions. These interventions must be effective when combating identified human errors. They must also help determine techniques that can be successfully integrated into the daily processes and routines of RNs and consequently stick to professional practices in the long term. Consequently, the Iowa Model was an appropriate theoretical framework to guide the education program development. I reviewed scientific evidence (peer-reviewed empirical and theoretical works) which helped develop the specific educational program. This part of the project was based on the use of secondary data sources. Section 3 includes additional details about the project. 6 Booth et al. (2017) made an important point according to which each specific healthcare setting has a specific effect on an individual nurse practice due to the established procedures, work culture, and environment. The project’s final stage concerned evaluation and assessment of the effectiveness of the developed educational intervention. The objective of the intervention was to help nurses develop the knowledge and skills for the safe administration of medication. To achieve the established objective, the group of nurses administered a survey designed by Gonzales (2010) especially for testing the effectiveness of nurse-led educational intervention. The purpose of my project was to identify internal and external factors most relevant to nurse medication administration errors within the chosen healthcare context; to develop an effective educational program for nurses; and to test the effectiveness of the developed and implemented program. Project success was validated by quantitative pretesting and posttesting. 7 Significance My project provided benefits and potential benefits to two major groups of stakeholders. First, all patients comprise a key stakeholder category. Sears, O'Brien- Pallas, Stevens, and Murphy (2016) pointed out that MAEs result in high mortality and morbidity rates, therefore compromising patient safety and health outcomes. Second, staff nurses comprise the other important group that benefited from the educational intervention. The intervention aimed to enhance their knowledge and their level of preparedness toward reducing possible human errors associated with medication administration, consequently enhancing their professional competency. Contribution to Practice In the literature review, several studies and reports suggested an overall high prevalence of injuries and other negative health-associated consequences. This negative situation is the result of healthcare workers who do not possess sufficient knowledge, skills, and attitudes (KSAs) to ensure safe medication administration (Dubovi et al., 2017; Gonzales, 2010; Härkänen et al., 2016). Within the studied local context, no significant effort was dedicated to solving the identified problem. Various learning approaches have been discussed within the context of improving educational outcomes of nurses, e-learning, experiential learning, and so forth (Dubovi et al., 2017; Härkänen et al., 2016). The existing evidence suggested integrating such activities and approaches into the traditional curriculum of nurse education to enhance the outcome of care (Härkänen et al., 2016). 8 Transferability of the Doctoral Project It is important to highlight that my project approach may apply only to the area in focus, that is, the administration of medication by RNs. The project’s results may not transfer to other important areas of nursing practice. Dubovi et al. (2017) pointed out that RNs often either receive insufficient training during their education or stop studying and gaining insight into the state-of-the-art evidence-based research at some point during their career. Dubovi et al. argued for the importance of holistic educational interventions at any point in the nursing career. For instance, context- and evidence-based educational programs may not only enhance professional performance of nurses via improvement of their KSAs, but also help address other issues relevant to their profession, for example, burnout and compassion fatigue (Berger, Polivka, Smoot, & Owens, 2015). Berger et al. (2015) pointed out that education-based interventions can significantly reduce various negative consequences associated with the nursing profession by increasing awareness, resilience, and strengthening knowledge of the latter. Positive Social Change The results suggest my project can serve as a trigger for positive social change. Dubovi et al. (2017) explained that the DNP’s key role is bridging the gap between theoretical knowledge and evidence-based research on the one hand, and practicing nurse professionals, on the other. DNPs can act as agents that stimulate education and knowledge-sharing among individual RNs and their teams. Project results demonstrate that the process of learning and systematic education (including organization-led interventions and self-learning) are relevant to the nursing practice at any point of their 9 career not only at the beginning, but also at later stages as experienced RNs. My project showed the importance of a patient-centered approach and safety as a pivotal component of nurse practice. The project significantly enhanced the level of safety during medication administration by the nursing staff. According to Dubovi et al. (2017), there exists a stigma in association with human error in general and errors when administering medication in particular. According to such a viewpoint and stigma, human error should be reprimanded and viewed as the result of individual underperformance (Berdot et al., 2016; Blignaut et al., 2017; Härkänen et al., 2016; Vrbnjak et al., 2016). To the contrary, Dubovi et al. (2017) suggested that human error does not emerge due to individual mistakes made by nurses. Human error is often the result of an organization-wide failure to ensure safety and knowledge-based work culture to reduce incidents of those human errors. The positive social change envisioned by my project concerns battling the existing stigma associated with errors during medication administration. Such errors are regarded as an inevitable part of nurses` performance. My project showed that the combination of individual and institutional efforts can enhance the discussed aspect of nurses` performance and mitigate risks of human error. Summary Human error during medication administration is a serious healthcare problem, leading to over 7,000 deaths annually. While multiple approaches have been suggested (e.g., organization-wide interventions, focus on building safety-oriented work environment), little effort has been dedicated to educating practicing nurses about possible causes and preventive strategies. My project bridged the gap between existing 10 evidence and the importance of systematic education and the negative consequences of errors while administering medication. The project also focused on bridging the theory with the specific chosen context—internal and external challenges experienced by RNs when administering medication within the clinic setting. Focus on such context helped to design the most effective holistic educational approach to increase knowledge of nurses regarding medication administration and to enhance their self-confidence about their relevant skills. My project resulted in outcomes that may promote positive social change within nursing practice. While the specific local context and nurse practices were specific to the project, the project was also based on a relevant underlying theoretical framework that included the Iowa Model of Evidence Based Practice. The following section is a comprehensive overview of the key theoretical bases for the project. 11 Section 2: Background and Context Introduction Medication errors are a highly common phenomenon within hospitals and clinical settings. Medication errors which may lead to various adverse drug events, increased readmission rates, and prolonged patient stays in the hospital (Berdot et al., 2016; Blignaut et al., 2017; Vrbnjak et al., 2016). A medication process consists of three main stages (prescription, delivery, and administration), with all three being prone to human error (Dubovi et al., 2017; Strickler et al., 2016; Vrbnjak et al., 2016). However, it is important to highlight the prevalence of medication errors occurring at the administration stage (over 33% of the cases). …