An Investigation into Factors that Contribute to Medication Administration Errors
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Transcript of An Investigation into Factors that Contribute to Medication Administration Errors
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SAFE MEDICATION PRACTICES: FACTORS CONTRIBUTING TO MEDICATION ERRORS IN THE
FORT ST. JOHN HOSPITAL IPU.
Breakout session D6 – Naomi Smith
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DISCLOSURE
Funding from BCPSQC
No conflict of interest
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PROJECT
Pyxis insufficient
Investigation:
Interviews, questionnaires, past errors
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SPECIAL FOCUS
Culture
At-risk behaviours
Issues to be resolved
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ASSUMPTIONS
Greater discourse
Lack of feedback
- Support, accountability, & education
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RECOMMENDATIONS
Culture of rush/busyness
Accountability
Feedback, education/orientation
Time management
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ACHIEVEMENTS
Proposal of solutions
Decreased occurrence
Increased conversation & awareness
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SOLUTIONS IMPLEMENTED
Transcription process
Time saving strategies
Acuity Based Care (ABC) Model
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SOLUTIONS IMPLEMENTED
Transcription process:
Prince Rupert
More difficult to ignore
Location, appearance, stamps
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SOLUTIONS IMPLEMENTED
Time-saving strategies:
Independent double check
Change policy
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SOLUTIONS IMPLEMENTED
Acuity based care model:
Kamloops
Severity
Care level required
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MOVING FORWARD
Evaluation
Cooperation and coordination
with unit staff
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WHO NEEDS TO BE INVOLVED?
Local team
Hospital administration
Nursing staff
Regional team
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RESULTS
No further transcription errors
Workload more manageable
PhD work
Continued evaluation
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AUDIENCE QUESTIONS