It has been estimated that medical errors, including medication errors and adverse events, rank as the 8th leading cause of death in the United States (Hoyert et al., 1999). An error is defined as “an unintended act (either of omission or commission) or as an act that does not achieve its intended outcome” (Leape, 2007).
Medication administration is a complicated process involving many overlapping systems and complex human factors (San et al., 2012). A failure in any one system or point in the process can cause an error—and this error often happens during the drug administration process (Hicks et al., 2006; Stavroudis et al., 2010). While some errors are benign, others can cause patient harm and/or death. Fortunately, technological advances have enabled many healthcare facilities to institute bar-code medication administration (BCMA), which has been shown to reduce medication errors in various settings in hospitals, including intensive care units, transitional care units, and acute care areas (DeYoung et al., 2009; Helmons et al., 2009; Paoletti et al., 2007). BCMA can prevent errors related to the timing of medications and has also been shown to reduce wrong-patient, wrong-drug, wrong technique and dose omission errors. However, BCMA as a safety technology is only as effective as its utilization. In other words, traditional medication administration practices must be altered in order to leverage the full safety benefit of BCMA.
Changing practice is never easy. And while the actual act of administering medication may be similar across areas, the workflows surrounding medication administration—from order to patient administration—varies widely. Staffing, patient population, pharmacy support, and even the built environment all have a profound impact on the workflows surrounding medication administration. UCSF Medical Center has implemented BCMA as the new safe medication administration method for many inpatient areas starting in the Spring of 2012. Nurses, pharmacists, and respiratory therapists have been trained for BCMA using a three pronged approach: viewing an online orientation module; attending a training class; and participating in simulated patient scenarios that focused on BCMA and medication administration workflows.
Simulation is the cornerstone of training in organizations requiring high reliability, such as aviation, nuclear power, and the military (Frengley et al., 2011). The Institute of Medicine (2000) has advocated HPS as an effective way of training healthcare professionals. To reduce variation and to reinforce medication safety processes, UCSF Medical Center instituted a simulated experience, alongside more traditional training approaches, to prepare healthcare professionals for BCMA. It is expected that the results of this study will yield insights that will have great impact to UCSF Medical Center. For example, the Department of Nursing Education and members of the simulation training team can revise and adapt simulation scenarios in the future by better understanding how healthcare professionals perceived the usefulness of this initial simulation experience.
- Daphne Stannard, RN, PhD, FCCM
- Maureen Buick, RN, MS
- Adam Cooper, RN, MSN
- Craig Johnson, RN, MSN, FNP
- Melissa Lee, RN, MS, GCNS-BC
- Sandy Ng, RN, MSN, RN-BC
- Kathy Lee, RN, PhD, FAAN – UCSF School of Nursing
Funded by UCSF 2012 Synergy Grant