NUR 409 Module 6 Project Two Medication Safety Strategies Example

Project Two: Three Strategies to Stop Time-Critical Doses From Falling Between Departments

[Student Name]

Southern New Hampshire University

NUR 409: Strategies for Quality Improvement in Healthcare

Project Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Project Two: Three Strategies to Stop Time-Critical Doses From Falling Between Departments

The Project One root cause analysis found three system causes behind late time-critical doses after transfer to 5 East, a composite medical unit: a handoff that does not carry the last dose time, an order-entry process that restarts the schedule at unit standard times and a supply process that does not prioritize first doses. The aim, set in the performance gap activity, is to raise the on-time rate from 71% to 95% within six months without duplicated doses. This plan proposes one strategy for each cause and tests them through Plan-Do-Study-Act cycles, the method of small tests of change described in the Model for Improvement (Langley et al., 2009). It argues that the order of testing matters as much as the strategies themselves: start with the change the unit controls, measure weekly and expand only when the data show improvement.

Strategy 1: A Required Last-Dose Field at Handoff

The first strategy makes the last administration time of every time-critical medication a mandatory entry in the electronic transfer handoff; the handoff cannot be marked complete without it. This is a forcing function, one of the stronger actions in root cause analysis guidance (National Patient Safety Foundation, 2015). Evidence from other handoff settings supports structured handoffs. A multicenter evaluation of a standardized resident handoff program at children's hospitals reported significant drops in both medical errors and preventable adverse events after the program began (Starmer et al., 2014). That study concerned physician shift handoffs rather than nurse transfers between departments, so the effect here cannot be assumed; it must be tested. The strategy addresses the leading cause from the gap activity, missing last-dose times, which accounted for 40% of late doses.

Strategy 2: Scheduling From the Last Dose

The second strategy changes order entry so that the unit's first dose of any drug on the time-critical list is timed by the computer from the dose already charted downstairs, and a pharmacist confirms the time during verification. National guidance asks hospitals to name their time-critical drugs and hold them to a half-hour window around the scheduled time (Institute for Safe Medication Practices, 2011); that guidance is only achievable if the scheduled time itself is correct. This is a standardization change that removes the need for a busy nurse to notice and correct the schedule. It requires informatics and pharmacy work and cannot be tested by the unit alone, so it is the second strategy in sequence.

Strategy 3: Targeted Cabinet Stocking

The third strategy stocks the ten time-critical medications most often needed as first doses after transfer in the unit's automated dispensing cabinet, and lets nurses remove a first dose on override before verification is complete, under rules the pharmacy writes. The evidence here is weaker. A 2024 systematic review found nine studies on automated dispensing cabinets and omitted or delayed doses; most suggested a positive effect on omitted doses, but only two linked missed doses to medication unavailability, and none reported results for delayed doses (Jeffrey et al., 2024). The strategy is still reasonable because the gap activity found unavailability behind 26% of late doses, but its effect must be measured carefully, and the balancing measure for early or duplicate doses becomes more important when overrides are allowed.

The PDSA Sequence

Table 1 shows the planned cycles. Each cycle has a prediction, a small scale and a decision rule.

Table 1

Planned Plan-Do-Study-Act Cycles for Time-Critical First Doses on 5 East

Note. Composite plan. Measures are reported weekly on the unit run chart.

Why Small Cycles and Weekly Data

Many improvement projects call their work PDSA without following the method. Taylor et al. (2014) reviewed 73 articles reporting PDSA and found that fewer than one in five showed a true series of repeated cycles and that only 15% of the articles analyzed in full reported using data collected at least monthly to decide how the cycles should progress. This plan is built to avoid those problems: the first test involves four nurses for one week, each cycle states its prediction in advance, and the lead measure is reviewed weekly. Starting with a paper checklist before building the electronic field lets the unit learn what information nurses actually need before asking informatics to program it.

Stakeholders and Communication

The plan depends on the emergency department, pharmacy and informatics as much as on 5 East. The emergency department's nurse manager and a staff champion will join the improvement team, pharmacy will review the cabinet list and the scheduling rule, and informatics will build the required field and scheduling logic. Staff on both units will see the run chart weekly, and the team will share results at each department's monthly staff meeting. Nurses involved in the original event have been invited to take part in testing, consistent with the just culture response described in Module 5.

Conclusion

Late time-critical doses after transfer have three system causes, and this plan pairs each with a strategy of appropriate strength: a forcing function at handoff, standardization in scheduling and targeted stocking. The evidence is strongest for structured handoffs and weakest for cabinet stocking, so each is tested in small cycles with predictions, weekly data and decision rules. If the cycles work as planned, 5 East will reach its aim of 95% on-time first doses and will have the data to show it.

References

Institute for Safe Medication Practices. (2011). ISMP acute care guidelines for timely administration of scheduled medications. https://www.ismp.org/sites/default/files/attachments/2018-02/tasm.pdf

Jeffrey, E., Dalby, M., Walsh, A., & Lai, K. (2024). Automated dispensing cabinets and their impact on the rate of omitted and delayed doses: A systematic review. Exploratory Research in Clinical and Social Pharmacy, 14, Article 100451. https://doi.org/10.1016/j.rcsop.2024.100451

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., . . . Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. The New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862