The purpose of this article is to address concerns related to the time frame allowed to administer the medications at skilled nursing facilities and the number of medication errors, especially ‘wrong time’ errors due to the apparently impossible task of being able to administer all of the medications, tube feedings, complete glucose and blood pressure checks and obtaining "missing meds" that have not been restocked on the med cart prior to the start of the shift.
What is the discrepancy?
There is a discrepancy between how medication administration should be completed and how nurses actually complete the medication administration especially during heavy peak times during the morning and evening medication pass. This article addresses the concern related to the time frame allowed to administer the medications at many skilled nursing facilities (SNFs) and the number of medication errors, especially ‘wrong time’ errors. Typical patient load is 20-22 patients. Most residents receive 10-20 medications and supplements during the morning medication administration time which includes tube feedings, intravenous (IV) antibiotics, breathing treatments, eye drops, and preparing crushed medications ordered to be administered at 8:00 am with a window from 7:00 am to 9:00 am. This seems to be an unrealistic task to complete. The most frequent medication error, research has shown, is wrong-time administration (Stokowski, 2012).
The Institute of Medicine (IOM) report “To Err is human: Building a safer health system” (1999) points out the high number of medical errors resulting in death, disability, financial costs, and loss of trust of the healthcare system. The report points out the fact that humans will make unintentional mistakes but most errors are caused by the healthcare “faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them (Institute of Medicine, 1999). The IOM report indicates that the healthcare system needs to change and put in place systems that will reduce risks for errors and promote learning from mistakes to prevent repeats of the same mistake rather than taking disciplinary measures (IOM, 1999).
The IOM report outlines several strategies to promote safer health care. As a result of the IOM recommendations, the Center for Patent Safety was created within the Agency for Healthcare Research and Quality (AHRQ) and has created the Patient Safety Network (PSN) website which includes various resources pertaining to patient safety issues. Healthcare educators and management are now promoting the importance of identifying and learning from mistakes. Each state has mandatory reporting systems which holds healthcare organizations and providers responsible for resolving and preventing errors. The mandatory reporting system covers errors resulting in death or serious injury. A voluntary reporting system covers errors that causes minimal or no harm. The IOM report recommends raising performance standards and expectations in safety, and implementing safety systems such as scanning medications (IOM, 1990).
Mahmood, Chadhury, and Gaumont (2009) study focused on factors contributing to medication administration errors in long-term care facilities. Mahmood et al. (2009) found limited research on medication errors in nursing home patients but identified several factors contributing to medication administration errors. Dim lighting, excessive noise, poorly designed work space, inadequate supplies, disorganized medication storage, distractions and interruptions, and heavy workloads due to staff shortages and turnover are factors that contribute to increased medication errors during medication passes. One study (Szczepura, Wild, & Nelson, 2011) concluded a high rate of medication administration errors occur in long-term residential care. One study (Roth & Wieck, 2015) concluded that nurses are frequently interrupted while administering medications. Many nurses may claim the ability and mastery of being able to multi-task, humans are not able to focus on multiple things at once and perform accurately (National Research Council, 2010).
Quality Improvement Process
The Plan-Do-Study-Act (PDSA) methodology is a scientific method for bringing about improvement by testing out changes on a small scale which is for action-oriented learning. Changes and modifications can be easily made in the procedure being tested among the small group of research participants. Key questions of the PDSA includes the following questions. “What are we trying to accomplish? How will we know if the change is an improvement? What changes can we make that will result in improvement?” (Institute for Healthcare Improvement, 2019, para. 1). PDSA involves testing a change “by planning it, trying it, observing the results, and acting on what is learned” (Institute for Healthcare Improvement, 2019, para.1). The nurse will use the PDSA method with the goal of decreasing medication wrong-time error and advocate for improvement in medication administration and decrease medication errors occurring at the skilled nursing facility.
The plan involved making observations of how nurses at a SNF administered the morning medications, observing times on and off the drug cart, and interviewing nurses on drug administration strategies and length of time to complete medication administration during morning and evening medication pass. Researching current literature on medication administration, medication administration errors, and medication errors in SNFs. The plan was to learn what the common medication errors were and ways to complete the medication pass within the allotted time to avoid wrong-time errors.
Studies shown that wrong time medication errors is the most common error made (Patient Safety Network, 2019). Medication “errors may be the result of individual-level slips and lapses, but may also result from system-level failures such as understaffing, human factors problems (e.g., poor process or equipment design), and other latent conditions” (Patient Safety Network, 2019, para. 2). Slips results from temporary lapses in memory during a task-oriented job duty, this could be caused by an interruption, stress, fatigue, or just a plain ‘brain glitch’ which everyone experiences on occasion. Latent conditions refer to faulty systems that leads to mistakes such as having various types of infusion pumps which operates differently causing increased likelihood of an error in programing by the nurse since each pump is programed differently. Other literature reviews reported similar findings which were discussed above. Stokowski (2012) found about two-thirds of medication errors are wrong-time administration and nurses tend not to report medication administration errors, especially wrong-time errors that doesn’t result in patient harm.
Observations and results of informal interviews revealed similar and interesting results. Common medication errors include medications and/or supplements not being administered but being documented as administered and most nurses reported inability to complete medication administration within the two hour window. One nurse was observed to complete the medication pass within the allotted time frame. The assistant director of nursing claimed she completed the medication pass within the allotted time on a consistent basis taking short cuts such as bringing both patients medications into the room at the same time with each medication cup clearly marked and relying off of memory when pouring meds. Barnsteiner (2017) reported that avoiding reliance on memory and having computer systems that are user-friendly are important in decreasing risk for errors and increasing patient safety. Most nurses took three and a half hours or longer to complete the medication pass which resulted in 90 minutes or longer where medications were administered outside of the time frame. Frequent ‘holes’ in the paper medication administration record (MAR) where nurses did not initial documenting the medication was administered. The SNF had no electronic MAR (e-MAR) system. Patients with no noticeable cognitive deficits have reported not receiving certain medications or supplements. There were missing medication packets not found in the drug cart nor stored in the refrigerator.
The financial impact of these issues includes insurance savings of medications that should have been ordered that were not. There are financial costs related to nurses working over-time to complete duties not completed during the shift, such as charting. There may be financial loss related to lawsuits pertaining to adverse effects from medications not being administered or being administered late. There are no budgetary expenses related to this PDSA research.
The goal after collecting the data was to complete the medication administration within the allotted time by utilizing strategies learned including decreasing interruptions and bringing both medications to the patients in the same room when possible. Sometimes this was not feasible if one patient receives insulin injections, eye drops, Miralax, inhalers, and approximately 20 medications and supplements during the morning med pass. Nebulizer breathing treatments were started first thing in the morning before certified nursing assistants (CNAs) got these residents up and took them to the dining/activity room for the day. Daily medication packets were marked indicating the time for administration occurring later in the day (ex. Lasix given at 4pm daily).
These steps have been implemented. Staff were informed not to interrupt nurses during medication administration except for emergencies. Patients were informed and reminded their non-drug related or non-critical needs will be addressed either after the medication pass or by their CNA. Evidence-based practice confirms limiting interruptions during peak times of medication administration decreases medication administration errors (Westbrook, Li, Hooper, Raban, Middleton & Lehnbom, 2017). Daily medications scheduled outside of the morning med pass were marked on the packet with the scheduled administration time. Medication was poured for both roommates and marked when the amount of medications can be easily carried into the patients’ rooms at the same time. Management was informed about the medications not received from pharmacy and plan to retrain nurses to order the medications per facility policy and will monitor pharmacy issues and address issues caused by pharmacy. Management now is limiting rotation of nurses to two units (two drug carts) to increase consistency and familiarity with only two drug carts.
According to one study (Jones, Johnstone, & Duke, 2016) nurses reported cutting corners to “manage their time and workload in the presence of resources and time constraints in busy and demanding clinical environments” and was justified due to limited time because “the nurse could not ‘physically get there’ to provide care that was perceived as being ‘ideal’ in the particular circumstances” (p. 2129). Jones, et al. (2016) reported that experienced nurses using critical thinking know which corners can be cut safely but novice nurses do not know due to lack of experience. Jones, et al. (2016) found “examples where nurses omitted steps in established processes for checking and documenting medications because this represented the only way to ‘get things done’ and achieve the goal of timely medication administration” (p. 2131).
Experienced nurses were often observed as cutting corners by not ordering or following up on missing medications. The author reduced the time of medication administration but continues to find medications missing requiring time to search for the medication, contact pharmacy/place order, and documenting and obtaining the missing med dose from the emergency kit (E-kit) which kept on another unit. Since most of the patients receive numerous medications, taking both patients’ medications into the room at the same time has not been effective during the morning pass. This has been useful during other med passes where there is less medications to administer per patient. Successful completion of the medication pass, in the opinion of the author, will occur per policy protocol and evidence-based practice within the allotted time frame. The patient will receive all medications ordered including scheduled supplements. Medications ordered will be available on the cart or stored in the refrigerator, if indicated, at all times. All MARs will be properly documented with no ‘holes’.
Continued research utilizing the PDSA method is still indicated. The time to administer the medications has not been cut down to the two hour window with the strategies discussed, therefore is not advised to expand to other clinical areas. Corporate plan to install e-MAR system by the end of 2019. Management report morning medication administration times will be changed from 8:00am to staggered times between 8:00am to 10:00am. This will expand the administration time to complete the medication pass from two hours to four hours. This will dramatically cut down on the wrong-time medication errors.
There are concerns if the current nurse-patient ratio, patients’ level of acuity, and number of medications to be administered makes it feasible for nurses to administer medications during peak medication passes within the allotted time. Many nurses take short cuts in order to complete tasks and meet job demands within the acceptable time frame (Jones, et al., 2016). Nursing programs and professional organizations advocate and promote evidenced-based practice, promoting improvement in health care quality, and patient safety (QSEN, 2019). Healthcare is evolving with focused research on patient safety. More research and collaboration among all stakeholders is needed to merge what is taught as the correct way with what is occurring in the ‘real world’ clinical setting.
Barnsteiner, J., (2017) Safety. In G. Sherwood & J. Barnsteiner (Eds.), Quality and Safety in Nursing: A Competency Approach to Improving Outcomes (2nd ed.). (pp.153-171), Hoboken, NJ: John Wiley & Sons, Inc.
Institute for Healthcare Improvement. (2019). How to improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges .aspx
Institute of Medicine (1999, November). To err is human: Building a safer health system. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
Jones, A., Johnstone, M. J., & Duke, M. (2016). Recognising and responding to ‘cutting corners' when providing nursing care: A qualitative study. Journal of Clinical Nursing, 25, 2126-2133.
Mahmood, A., Chaudhury, H., & Gaumont, A. (2009). Environmental issues related to medication errors in long-term care: Lessons from the literature. Health Environments Research & Design Journal, 2(2), 42-59.