reduce medication errors in the community - aiic
TRANSCRIPT
© Canadian Nurses Association, 2012
Reduce medication errors in the community
CNA Webinar Series: Progress in Practice
Christina GodfreyAssistant Professor, School of Nursing
Queen’s University
Kim SearsAssistant Professor, School of Nursing
Queen’s University
May 27, 2014
Norma Freeman, RN, MS, MBA
Nurse Advisor, Practice & PolicyCanadian Nurses Association
Kim Sears, RN, PhDAssistant Professor, School of Nursing
Deputy Director, Healthcare Quality Queen’s Joanna Briggs Collaboration
Queen’s University
Objectives
At the end of the session, participants will:1. Gain insight into the risk of error at each stage
of the medication delivery process.2. Understand the unique issues of medication
delivery in the community.3. Understand key findings from the systematic
review and their implications for nurses.
Medication Delivery
• The delivery of a single medication involves 30 to 40 steps, each of which increases the risk for error (Leape, 2007).
• The process of medication delivery with an interdisciplinary team involves:– Prescribing– Dispensing – Administrative
Background: Medication Safety
• Medication safety is a key issue in the quality and patient safety movement.
• Medication delivery is complex in all areas of health care.
• Medication delivery provides numerous opportunities for errors.
• Medication errors in the community environment are understudied.
Medication Safety in Hospital
It is estimated that at least one medication error occurs per day per adult hospitalized patient (IOM, 2007).
Community: Medication Safety Worldwide
• For every 1 self-reported medication error in the hospital, 4 were reported in the community.
• In spite of research attempts to determine underlying causes of medication incidents and error reduction strategies, little is known about medication safety in the community worldwide.
Community: Medication Safety in Canada
• Over 422 million prescriptions dispensed in the community per year in Canada.
• 28% of all emergency visits to hospital occur because of drug related problems in the community (Patel & Zed, 2002).
Christina Godfrey, RN, PhDAssistant Professor, School of Nursing
Co-Director/Methodologist, Queen's Joanna Briggs Collaboration (QJBC)
Queen’s University
Queen’s Joanna Briggs Collaboration (QJBC)
• QJBC is the Canadian collaborating centre of the international Joanna Briggs Institute (JBI)
• QJBC researchers perform systematic reviews – focus on patient safety
Review Objective/Question
Purpose of the review: To synthesize the best available evidence to answer the review question:• What are the incidence, prevalence and
contributing factors associated with the occurrence of medication errors for children and adults in the community setting?
Systematic Review
• Adults and children living in the community that have experienced a medication error.
– (includes living at home/ residential homes)
• 21 total studies - 8 focused on pediatric population
• Countries = USA, UK, Australia, Denmark, India
• Contributing factors identified from perspectives of providers and patients/families
Systematic reviewOverall Findings
Key contributing factors – provider perspective– Dosing errors, misreading prescriptions, workload,
calculation errors
– Similar-looking medications, similar-looking containers/packaging and similar drug names – strong causal factors for errors
– Poor communication or lack of communication –frequently contribute to medication errors
Findings of the review cont.
Key contributing factors – patient/family perspective– Confusion or lack of knowledge of medications– Distraction and fatigue– Environment factors can increase medication errors
• homes that were hot• homes without adequate air circulation, lighting, space
– Poor communication or lack of communication –frequently contribute to medication errors
Pediatric Findings
• High risk for errors in the administration stage
• Issues with dosing are noted as a primary contributor to the medication error
• The younger the child, the higher the risk of errors
Nursing Implications
• Medication errors can occur anywhere within the stages of medication delivery
• Recommendations – reducing errors - providers: • Reduce workload stress, as possible
• Separate medicines with similar packaging, as possible
• Ensure adequate lighting
• Promote clear communication (validate patient/family understanding)
Nursing Implications cont.
• Recommendations for nurses to help patients:• Educate patients about their medications• Ensure adequate lighting • Aids – dispensers, timed containers • Communication between caregivers
• Pediatric errors• Highly vulnerable population• Extra vigilance – especially dosing
Take-home messages
• Medication errors can occur in any stages of medication delivery.
• Financial and human costs of medication errors in the community are large.
• Educate, assess and support patients/families• Important – report errors.• The community is lacking an established
reporting system.
Related ResourcesRelated CNA webinars:
– Discover new medication practices webinar– Home care nurses – Get informed! How to respond to the
shift in health-care needs– Learn more about advancing public health nursing in
schools– Get tips and hints for using e-Therapeutics: Available on
NurseONE.cahttps://cna.webex.com/tc0601l/trainingcenter/record/navRecordAction.do?siteurl=cna&firstEnter=1
MyMedRec App: http://www.knowledgeisthebestmedicine.org/index.php/en/app/
© Canadian Nurses Association, 2012
For more information:
Christina [email protected]
Norma [email protected]
Photo credits: iStock
© Canadian Nurses Association, 2012
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