Jie Xu1, Carrie Reale, Jason M Slagle, Shilo Anders, Matthew S Shotwell, Timothy Dresselhaus, Matthew B Weinger. 1. Jie Xu, PhD, is Research Instructor, Department of Anesthesiology, School of Medicine, Vanderbilt University, and The Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee. Carrie Reale, RN-BC, MSN, is Informatics Nurse Specialist, Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee. Jason M. Slagle, PhD, is Associate Professor of Anesthesiology; and Shilo Anders, PhD, is Assistant Professor of Anesthesiology, School of Medicine, Vanderbilt University, and The Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee. Matthew S. Shotwell, PhD, is Assistant Professor of Anesthesiology and Biostatistics School of Medicine, Vanderbilt University, and The Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee. Timothy Dresselhaus, MD, MPH, is Chief of Primary Care Service, VA San Diego Healthcare System, and Clinical Professor, Department of Medicine, University of California, San Diego. Matthew B. Weinger, MD, is Professor and Vice Chair of Anesthesiology, Professor of Biomedical Informatics and Medical Education, Norman Ty Smith Chair in Patient Safety and Medical Simulation, School of Medicine, Vanderbilt University; Director, The Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center; and Senior Physician Scientist, Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee.
Abstract
BACKGROUND: Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management-especially medication-related events (MREs)-provides an approach to analyze and improve medication safety and quality. OBJECTIVES: The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs. METHODS: We conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts. RESULTS: MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts. DISCUSSION: Most of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.
BACKGROUND: Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management-especially medication-related events (MREs)-provides an approach to analyze and improve medication safety and quality. OBJECTIVES: The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs. METHODS: We conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts. RESULTS: MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts. DISCUSSION: Most of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.
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