Field of Work: Improving hospital medication management to prevent patient harm from medication errors
Problem Synopsis: Medication errors in hospitals are common. A 2006 Institute of Medicine report estimates that a patient on average is subjected to at least one medication error per day. While only a small portion of these mistakes results in patient harm, serious injuries, including fatalities, do occur.
Synopsis of the Work: Interdisciplinary research teams at four institutions examined nursing's role in—and contribution to—the management of medications and prevention of medication errors in hospital and transitional care settings.
Two of the teams evaluated nurse-led interventions to resolve discrepancies between medications that patients are prescribed while in the hospital and those they actually take at home.
The teams, which worked independently on different aspects of the medication process, were based at Rutgers College of Nursing (Newark, N.J.), University of Wisconsin-Madison College of Engineering (Madison, Wis.), Johns Hopkins Hospital (Baltimore) and Washington State University College of Nursing (Spokane, Wash.)
Among the key findings:
- Hospital medical-surgical nurses engage in six "patient-focused" medication safety practices to prevent errors from reaching patients, according to analysis of interviews with 50 New Jersey hospital nurses. (Rutgers College of Nursing)
- An assessment of nursing medication management practices at two Wisconsin hospitals identified 21 major medication management "failure modes" (the ways that the medication management process can break down) and 71 contributing factors. (University of Wisconsin-Madison College of Engineering)
- An intervention to improve medication reconciliation found that 226 of 563 participating hospital patients (40%) experienced a medication discrepancy on admission or discharge. Of those 226 patients, 162 (72%) had a discrepancy rated potentially harmful. (Johns Hopkins Hospital)
- Home care patients participating in an intervention to improve medication reconciliation (a process to prevent harmful drug events) had significantly fewer emergency department visits during the first 30 days after hospitalization compared to control group patients. However, there was no statistically significant difference in the groups' 30-day rehospitalization rates. (Washington State University College of Nursing)