NUR 683 Module 3 Milestone One Example

Milestone One: Medication Administration Errors, Interruptions and Barcode Scanning on a Telemetry Unit

[Student Name]

Southern New Hampshire University

NUR 683: Patient Safety and Quality Capstone

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: Medication Administration Errors, Interruptions and Barcode Scanning on a Telemetry Unit

A safety capstone stands or falls on its baseline. If the problem is measured badly, no one can tell whether the intervention helped. This milestone defines the medication administration problem on the cardiac telemetry floor at Ridgeview Memorial with measures taken by direct observation, explains why the unit's incident reports understated it, sets out why the problem matters and ends with operational definitions, a PICOT question and aims.

How the Baseline Was Measured

Over two weeks, the student and a unit pharmacist observed nurses during medication passes on all three shifts, following nurses from preparation through documentation. Nurses consented, were told that observations were for system improvement and would not be used for individual evaluation, and could stop at any time. Each administration was compared with the active order and recorded for clinical errors, procedural failures, interruptions and scanning. Observers intervened only when a clinical error was about to reach a patient. In total, 412 administrations to 97 patients by 26 nurses were observed.

Direct observation was chosen deliberately. It is labor-intensive and can make staff more careful while watched, but it detects errors that no one notices or reports and gives a true denominator of doses given.

What the Observation Found

Thirty-eight of the 412 administrations, 9.2 per 100, contained at least one clinical error. The most frequent types were wrong time, meaning more than an hour early or late for a time-critical drug, omitted doses and wrong dose, and three errors involved high-alert drugs, two with insulin and one with heparin. None caused lasting harm, although one patient needed extra glucose checks after an insulin error. Procedural failures, such as not checking identity or not labeling a prepared syringe, occurred in 21% of administrations.

Interruptions broke into 52% of administrations, averaging 0.9 per dose, mostly from other staff, phone calls and alarms, and more often during the morning pass. Barcode scanning of both the patient and the medication occurred in 79% of administrations; the patient alone was scanned in 84% and the medication alone in 88%. Scanning was least reliable in rooms without a wall-mounted scanner. In the three months before observation, the unit filed eleven medication error reports.

Table 1. Baseline from Direct Observation (412 Administrations)

Note. Figures are illustrative for the composite unit.

Why Reports Understated the Problem

The contrast between 38 observed errors in two weeks and roughly four reports a month is not surprising. Classen et al. (2011) compared methods of finding adverse events and found that voluntary reports detected only a small fraction of what a structured chart review uncovered. Reports depend on recognition and willingness, both of which are limited when errors cause no visible harm or when staff fear blame. The unit's leaders had judged its safety by the wrong measure.

Why the Problem Matters

Most observed errors caused no harm, but the ones involving insulin and heparin show how close the unit sits to serious injury. Westbrook et al. (2010) found that each interruption during administration increased the likelihood of both procedural failures and clinical errors, and that the risk of a major error roughly doubled at four interruptions. The unit's interruption rate places it squarely in the zone that research links to harm.

Barcode scanning is the unit's main technical defense, and it is only partly in use. Poon et al. (2010) studied the introduction of barcode verification with an electronic administration record in a large academic hospital and found meaningful reductions in administration errors and in potential adverse drug events on units that adopted it. Those benefits depend on scanning every patient and every dose; a defense used in four of five administrations leaves the fifth unprotected.

For the organization, medication errors carry costs in extra monitoring, longer stays and liability, and they erode staff confidence. For nursing, medication administration is the last point at which an error can be stopped before it reaches the patient.

Limits of the Baseline

The baseline has weaknesses that the project will carry forward honestly. Nurses who know they are being watched tend to work more carefully for the first few days, so the true error rate is probably higher than 9.2 per 100. Two weeks is a short window, and it fell in a month with lower census than usual. Observers could not see every step of every dose, particularly when two nurses worked at once, and judgments about whether a dose was on time depended on the accuracy of scheduled times in the record. To reduce these effects, the same two observers will repeat the method after the intervention, at the same times of day and for the same length of time, so that any bias applies to both periods alike.

Operational Definitions

A clinical error is any difference between the administered dose and the prescriber's order or hospital policy in patient, drug, dose, route, time, form or omission, with wrong time defined as more than 60 minutes from the scheduled time for time-critical drugs. An interruption is any occasion when a nurse stops a medication task to respond to another person, device or event. Full scanning is scanning of both the patient's wristband and the medication barcode before administration. The denominator for each measure is observed administrations.

PICOT Question and Aims

Among nurses giving medications to adults on a cardiac telemetry floor (P), would a bundle that protects medication preparation from interruption and supports full barcode scanning (I), set against current practice (C), lower observed clinical errors per 100 administrations (O) within twelve weeks (T)?

The project has three aims: to cut interruptions per administration by at least 40%, to raise full scanning to 95% or higher and to reduce observed clinical errors by at least a third, while tracking time to complete the morning pass as a balancing measure so that the bundle does not delay care.

Conclusion

The unit has a measurable problem that its usual data concealed: about nine errors per 100 doses, frequent interruptions and incomplete use of barcode scanning. The next milestone will review the evidence on interventions that reduce interruptions and improve scanning.

References

Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., Whittington, J. C., Frankel, A., Seger, A., & James, B. C. (2011). 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30(4), 581-589. https://doi.org/10.1377/hlthaff.2011.0190

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690. https://doi.org/10.1001/archinternmed.2010.65