Blog

Safety Improvement Plan Toolkit Sample Paper

  • Post category:Uncategorized
  • Reading time:17 mins read

Safety Improvement Plan Toolkit Sample Paper

Safety Improvement Plan Toolkit: Eliminating Medical Errors

Patient safety and healthcare service quality are inseparable elements. More importantly, efforts to ensure safe healthcare processes, reduce health hazards, and empower employees to enhance effective services are gaining popularity in healthcare contexts. The growing concern about patient safety emanates from the urge to eliminate process errors, patient injuries, and medical/economic burdens associated with medication errors. This safety improvement plan toolkit targets to expound on workplace safety parameters and provide insights about leadership obligations, potential strategies, and efforts to harness safe healthcare processes.

Annotated Bibliography

In this study. Mania et al. (2018) examines reported data on medication error trends in an Australian Pediatric hospital over a five-year period. The study utilized a retrospective audit to analyze five-year data submitted via an online voluntary reporting system and includes data between 1st July 2010 and 30th June 2015. The study established that a total of 3340 medication errors were reported over the said period, which, compared with combined admissions and presentations, represents an error rate of .56%.

The study further notes that among the identified communication-related factors associated with medication errors include trade name confusion, drug labeling and reference materials. The most common communication-related factor, according to the study, is problems with record documentation, which represented 17.9% of the sampled data.

Specifically, the study identifies failures to check patient documentation on allergies and weight confusion leading to medication errors. The study also identified instances where medication labelling and content were incorrect. The study thus concludes that communication-related factors contribute to medication errors reported in hospital settings.

In this article, Ooi et al. (2017) argue that incorrect or incomplete medication information in medical discharge summaries is prevalent. The study thus sought to investigate the extent to which medication information presented in pharmacist-prepared Discharge Medication Management Summary (DMMS) provides accurate medication information and changes to the general practitioners. The researchers intervened by requiring ward pharmacists to use the DMMS in communicating medication changes to GPs and leveraged a retrospective audit at baseline and post-DMMS implementation. At baseline, the researchers noted that doctors documented about 45.9 percent of medication changes in the discharge summary (DS).

However, the post-intervention audit revealed that pharmacist-prepared DMMS documented more medication changes than doctor-prepared DS, representing 72.8% versus 31.5% respectively. Further, the study revealed that most pharmacists documented increasingly more changes in medication classes, including analgesics, cardiovascular, endocrine, respiratory and endocrine drugs, and post-intervention.

Given the pharmacist’s efficacy in documenting medication information and changes, the researchers argue for the expansion of the roles of hospital pharmacists in preparing discharge medication information, specifically in partnership with doctors to ensure improved medication accuracy transmitted to the GPs.

Workplace Distractions and Medication Errors

This qualitative descriptive research paper aims to establish workplace distractions’ role in the prevalence of medication errors and compromised patient safety. The article explains distracted practices as growing concerns for healthcare professionals in today’s complex, technology-dominated, care-centered workplace settings. Practice distractions emanate from individual interactions with the environment and technologies when attempting to enhance their performance and realize set expectations. These considerations render process distractions detrimental to human functioning in situations that require adequate cognitive investment and appropriate utilization of professional expertise.

To explain the essentiality of understanding workplace distractions and their roles in contributing to increased medication errors, the researchers applied integrated observations and semi-structured interviews to obtain opinions from registered nurses (RNs), medical doctors (MDs), and pharmacists. The research paper utilizes a conceptual framework based on the distracted during the model. The framework includes several sub-strands like the availability of cognitive resources, cognitive workload, mental distraction, and increased error risks. Data collection and sampling methods: the researchers applied observations and interviews to get responses from RNs, MDs, and Pharmacists in various departments of an academic medical center (AMC) in Massachusetts.

A total of 12 RNs, 11 MDs, and nine pharmacists participated in the study. Participants identified distractors such as noise in acute care as the precursor for medical errors. According to research findings, other causal factors for medication errors include a lack of available cognitive resources, individual differences, team awareness, and time. This source is authentic in providing potential causes of distracted practices and their contributions to increased medical error prevalence.

This research investigates the actual and potential causal connections between interruptions and medical errors and if Interventions may reduce the possible harm. The researchers introduced a framework and criteria for evaluating how strong evidence implies casualty. This framework entails many Bradford Hill criteria and various metanarratives such as psychology, epidemiology, quality improvement, and cognitive system engineering. The research paper highlights that the recent growth of interest in interruptions and disruptions in healthcare draws inspiration from their potential to compromise patients’ safety. Bradford Hill criteria for attributing causality:

According to the source, the Bradford Hill criteria cover nine properties for attributing causes and effects of workplace distractions. Some of the requirements include association (Strength, consistency, specificity of associations), time gradient (biological gradient and temporal contiguity), generality, and experiment. The paper concludes that the Bradford Hill criteria and their subsequent sub-strands help evaluate the relationships between healthcare interruptions, clinical errors, and the potential for causing adverse effects to patients.

Understanding the role of interruptions and workplace distractions is significant in empowering explanations of how medical errors result. Workplace distractions by various stimuli, such as noise, may lead to compromised operations if the subsequent healthcare operations require cognitive interventions. The research harmonizes two conceptual frameworks (the Bradford Hill criteria and metanarratives) to explain causal factors for distractions and their contributions to medication error prevalence. It is valid to argue that the research is reliable in empowering Knowledge about the inputs of distractions to medicating errors. 

Medication errors emanate from various factors. This study investigates how familiar individual and environmental factors interact and result in errors. The source defines medication administration as a high-volume and high-risk activity that require appropriate expertise and immense accuracy. In attempts to ensure safe medication administration, nurses play a pivotal role in optimizing individual performance and controlling environmental factors to reduce medical-related errors. Medication errors are among the most prevalent mistakes that account for social over 1.5 million injuries annually. According to these sources, different factors contribute to the prevalence of medication errors.

These factors include inadequate Knowledge, failure to follow set policies and procedures, individual issues, and system failures. This study’s primary focus is to present possible causes of errors that prevail due to workplace issues and personal attributes. The source highlights that nurses and other healthcare providers operate in complex environments with diverse error-provoking interruptions, distractions, and cognitive loads. These factors affect how they undertake essential medical activities such as medication administration.

Strategies to Eliminate Medication Errors

Efforts to address and eliminate medication errors rely on multiple strategies. This paper provides a systematic review of the literature on several approaches such as Lean, Six Sigma, and Lean Six Sigma (LSS). These interventions, tools, and techniques are fundamental in reducing medication errors in healthcare institution settings. The researchers reviewed top journals from reputable electronic databases like Medline, PubMed, Web of Knowledge, Scopus, EMBASE, CINAHL, PsycINFO, and EBSCOhost. The primary inclusion criteria for scientific journals included the year of publication (1996-2016) and emphasis on methodologies such as LSS, Lean, and Six Sigma.

The paper accommodates various themes like Lean and Six Sigma tools/Techniques for reducing medical errors, LSS project selection, types of medication errors, and Six Sigma Methodologies. Types of medication errors: the study presents possible medical-related errors that include dispensing, administration, order misinterpretation, and omission errors.

Lean and Six Sigma Methodologies: these are process evaluation strategies that encompass elements like defining the scope and problem identification, determining the root causes of the problem, improving current situations, and ensuring process sustainability.  The LSS model entails aligning projects to the mission, setting measurable goals, senior management’s commitment to overseeing projects, and process improvement. The source provides meaningful explanations about the implementation of LSS methodology to reduce medication errors.

Personal issues: nurses should integrate their cognitive attributes with psychomotor and practical care skills. When distractor elements are present in an organizational setting, they may affect how healthcare practitioners utilize their skills to maintain patient safety, ensure effective processes, and complete patient care tasks. The researchers applied a hierarchical design by embracing unit analysis of a Medication administration episode. The study’s setting involved virtual hospital networks with 200 or more beds and a defined medical-surgical unit. The source is authentic and fundamental, describing interruptions, distractions, cognitive loads, and their contributions to elevated medication errors.

In this study, Fried et al. (2017) assessed the efficiency and effectiveness of the Tool to Reduce Inappropriate Medications (TRIM), which is a web tool that links electronic health records (HER) and a clinical decision support system. The authors utilize a randomized clinical trial in a Veterans Affairs Medical Center. The study sampled 128 cases (N=128), with the inclusion criteria being veterans, 65 years or older, prescribed 7 or more medications, and managed through the TRIM. The intervention tool, the TRIM, serves to extract information relating to medications and corresponding chronic conditions from the EHR and allows one to enter data obtained from brief chats with patients during the assessment.

The objective of this additional data is to enable the identification and reconciliation of discrepancies, “potentially inappropriate medications (PIMs), and potentially inappropriate regimens relating to the prescribed medications” (Fried et al., 2017). The researchers then used the Patient Assessment of Care for Chronic Conditions (PACIC) subscales to determine the efficacy of shared decision-making, clinician and patient communication, and medication changes.

While the results showed no significant difference in PACIC ratings between TRIM (29.7%) and control group (15.6%) participants, adjusting for covariates and patient clustering revealed more active patient and facilitative clinician communication via TRIM. This further translates into more medication-related communication among practitioners and patients. The study thus concludes that the use of TRIM improves communication regarding medications and the accuracy of patient medication documentation.

Analyzing causal factors and workplace aspects that facilitate medication errors require appropriate approaches. This study presents the Systems Engineering Initiative’s significance for the patient safety (SEIPS) model in analyzing factors that affect medication safety. The other study’s purpose is to establish the applicability of Lean methodology tools in identifying system vulnerabilities that affect improvement activities.

The investigators applied a non-experimental, descriptive design to analyze critical factors related to medication administration practices in the mental health setting. The project was in a 16-bed, non-hospital crisis residential center in the southeast United States. It accommodated views from 4 full-time registered nurses (RNs), one full-time licensed practice nurse (LPN), and four part-time registered nurses. The SEIPS model: this framework is appropriate for analyzing factors that affect medication safety. The researchers presented different work systems such as technology, tasks, employees, organization, and environment to influence data collection.

The study found that disruptions during medication processes, pharmacology training needs, and documentation processes are profound opportunities for safety improvement measures. The source concludes that different healthcare settings pose challenges to safe medication administration practices. For example, mental healthcare settings may compromise patient safety interventions due to distractions and complex working conditions. However, there are several improvement opportunities. For instance, the study highlights training nurses on psychotropic medications and improving the documentation system as fundamental safety improvement approaches. These contentions render this source effective in providing prospective guidelines for quality and safety improvement in a healthcare organization context.

Infusion-associated medication errors are among the most detrimental process errors that can cause the most significant harm to patients. This study assembles findings from a 21-year review of errors and near-miss reports from a national medication error-reporting program. Content analyses highlighted that most errors included improper dosage, mistaken drug choice, skill-based slips, memory lapses, and knowledge-based mistakes. Before establishing the potential opportunities for eliminating medication errors, the study defines infusion-associated medical errors as mistakes emanating from improper administration of fluids via IV and other routes, including electrolytes, medications, and other products. Despite many strategies to eliminate these errors, patients are susceptible to healthcare mistakes that compromise medical services’ quality and safety.

Nurses are at risk of committing medication errors due to the complex working conditions and procedural difficulties associated with medication administration processes. The study defines best practices prescribed and accepted as correct or most effective as commercial or professional procedures. The researchers used the human error theory (HET) to explain the origin of organizational failures. The theory attributes institutional shortcomings to a lack of leadership commitment, blurred safety responsibilities, and inadequate training. Therefore, the study concludes that best practices for eliminating infusion-associated errors include double-checking the medication process, developing a learning culture, providing medication-specific Knowledge, and using prescription-improvement methods. This source is ideal for presenting guidelines for safety and quality improvement.

This descriptive cross-sectional study aimed to determine individual and professional factors that affect emergency unit nurses’ tendency to make medical errors and their perceptions towards these mistakes in Turkish healthcare institutions. The study provided insightful background information about the emergency units’ susceptibility to prevalent medical errors. This vulnerability aspect emanates from complex and dynamic workplace structures, noise, and rapid movement in and out of emergency units.

This research’s data collection method was data surveys targeting to obtain perceptions of 284 volunteer nurses who agreed to participate in the study. The researchers grouped data based on medical error tendency and medical error attitude scales. Research findings: 40.1 percent of the nurses agreed they had witnessed medical errors. 17.6% of these medication mistakes emanated from wrong medication administration in the form of incorrect dosage. Regarding the factors contributing to these errors, 91.2% of the nurses stated excessive workload as the primary cause.

In comparison, 85.1% cited the insufficient number of professionals and the subsequent effects as causes of medication errors. 75.4% stated exhaustion, burnout, and fatigue as the principal reasons for the prevailing medication mistakes. Relevance of the study: this research is essential in advocating for increased awareness about medical errors, consistent training to reduce mistakes, the development of procedures and protocols specific to healthcare emergency units, and the creation of influential workplace culture that accommodates proper reporting mechanisms and patient safety mindsets.

The degree of medication errors varies across the different medications. This study utilized ME incident reports obtained from the risk management department of five hospitals. The researchers extracted data from previous research done at five hospitals from the southeast region of the US. During the data extraction process, the researchers obtained a sample of 2336 observations. The study identified medication mistakes made by nurses to drug classifications, specific drugs, and their consequences in different hospital departments. The study’s purpose: researchers investigated the association between medication errors and their effects on patient safety. They measured mistake severity from least severe to most severe. Some classification criteria included errors that didn’t reach patients, errors with no harm, errors that got patients and increased monitoring, and mistakes that led to injuries.

Research findings: while Medication errors (MEs) varied across hospital units, 35% of the total reported medication mistakes occurred in medical-surgical units, 14.7% in Intensive Care Units (ICUs), and 13.3% in intermediate care. Relevance of the study: the research’s statistical findings outlined the correlations between different hospital units and medication errors. For instance, hospital units with complex medication administration activities had more medication-related mistakes. Therefore, it is possible to commence safety improvement Interventions in these units to reduce the prevalence of these errors. The source presents interventions such as continuing education, capacity building, and training to minimize costly mistakes. This article is crucial in inspiring safety and quality improvement interventions.

Many technological approaches may reduce the prevalence of medication mistakes. This study establishes the importance of using barcode techniques to reduce medication administration errors. The researchers used the updated system sauces model theory by Felons and McLean as the principal research framework. Significance of the success model: the framework served to investigate the effects of systems, information, and service quality on user satisfaction.

The researchers defined several terms: system quality, information quality, service quality, user satisfaction, and usage benefits for nurses to streamline the research framework. Study site: the researchers conducted this study in a medical center in southern Taiwan after the January 2012 deployment of the Barcode Medication Administration (BCMA) techniques at 6 to 8 mobile nursing stations. Study sample size and data collection method: a total of 38 registered nurses (RNs) answered open-ended questions about the applicability of the BCMA strategy in reducing medication errors.

The respondents noted that the Barcode Medication Administration strategy effectively facilitated accurate medical records and provided nurses with opportunities for up-to-date drug information. Although there were negative comments about computer crashes, poor network connectivity, system constraints, and other factors that affected the applicability of BCMA, many positive comments highlighted the effectiveness of this strategy in reducing medication administration errors. This research is essential in providing a prospective entry of a technology-oriented design in tackling costly medication errors.

References

  • D’Esmond, L. (2016). Distracted Practice and Patient Safety: The Healthcare Team Experience. Nursing Forum, 52(3), 149-164. https://doi.org/10.1111/nuf.12173
  • Fried, T. R., Niehoff, K. M., Street, R. L., Charpentier, P. A., Rajeevan, N., Miller, P. L., Goldstein, M. K., O’Leary, J. R., & Fenton, B. T. (2017). Effect of the Tool to Reduce Inappropriate Medications on Medication Communication and Deprescribing. Journal of the American Geriatrics Society, 65(10), 2265–2271. doi:10.1111/jgs.15042
  • Kiymaz, D., & Koç, Z. (2018). Identification of factors that affect the tendency towards and attitudes of emergency unit nurses to make medical errors. Journal of Clinical Nursing, 27(5-6), 1160-1169. https://doi.org/10.1111/jocn.14148
  • Lin, J., Lee, T., & Mills, M. (2018). Evaluation of a Barcode Medication Administration Information System. CIN: Computers, Informatics, Nursing, 36(12), 596-602. https://doi.org/10.1097/cin.0000000000000459
  • Manias, E., Cranswick, N., Newall, F., Rosenfeld, E., Weiner, C., Williams, A., Wong, I. C. K., Borrott, N., Lai, J., & Kinney, S. (2018). Medication error trends and effects of person-related, environment-related and communication-related factors on medication errors in a paediatric hospital. Journal of Paediatrics and Child Health, 55(3), 320–326. doi:10.1111/jpc.14193
  • Muroi, M., Shen, J., & Angosta, A. (2017). Association of medication errors with drug classifications, clinical units, and consequence of errors: Are they related? Applied Nursing Research, 33, 180-185. https://doi.org/10.1016/j.apnr.2016.12.002
  • Ooi, C. E., Rofe, O., Vienet, M., & Elliott, R. A. (2017). Improving communication of medication changes using a pharmacist-prepared discharge medication management summary. International Journal of Clinical Pharmacy, 39(2), 394–402. doi:10.1007/s11096-017-0435-5
  • Sanderson, P., McCurdie, T., & Grundgeiger, T. (2019). Interruptions in Health Care: Assessing Their Connection with Error and Patient Harm. Human Factors: The Journal of The Human Factors and Ergonomics Society, 61(7), 1025-1036. https://doi.org/10.1177/0018720819869115
  • Shitu, Z., Hassan, I., Aung, M. M. T., Kamaruzaman, T. H. T. & Musa, R. M. (2018). Avoiding Medication Errors through Effective Communication in Healthcare Environment. Movement, Health & Exercise, 7(1), 113-126. http://dx.doi.org/10.2139/ssrn.3573437
  • Steele, M., Talley, B., & Frith, K. (2018). Application of the SEIPS Model to Analyze Medication Safety in a Crisis Residential Center. Archives of Psychiatric Nursing, 32(1), 7-11. https://doi.org/10.1016/j.apnu.2017.09.005
  • Thomas, L., Donohue-Porter, P., & Stein Fishbein, J. (2017). Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors. Journal of Nursing Care Quality, 32(4), 309-317. https://doi.org/10.1097/ncq.0000000000000256
  • Trakulsunti, Y., Antony, J., Ghadge, A., & Gupta, S. (2018). Reducing medication errors using LSS Methodology: A systematic literature review and key findings. Total Quality Management & Business Excellence, 31(5-6), 550-568. https://doi.org/10.1080/14783363.2018.1434771
  • Wolf, Z., & Hughes, R. (2019). Best Practices to Decrease Infusion-Associated Medication Errors. Journal of Infusion Nursing, 42(4), 183-192. https://doi.org/10.1097/nan.0000000000000329