Seattle-based Virginia Mason Medical Center reduced nursing medication administration errors roughly 72.8 percent in about a year and a half by combining Lean improvement techniques with direct observation, according to a study in the Joint Commission Journal on Quality and Patient Safety.
Virginia Mason Medical Center combined the Collaborative Alliance for Nursing Outcomes Medication Administration Accuracy Quality Study with Lean quality improvement strategies to improve medication safety. Lean techniques aimed to improve the medication room layout, apply visual controls and implement nursing standard work, according to the study.
Researchers analyzed improvement on six safe practices:
1. Comparing medication with medication administration record
2. Labeling medication
3. Checking two forms of patient identification
4. Explaining medication to patient
5. Charting medication immediately
6. Protecting the process from distractions/interruptions
Trained nurse auditors observed medication administration. At baseline — measured from January to March 2010 — there were 83 safe-practice violations per 100 doses and 10.3 medication administration errors per 100 doses. After the intervention, measured in a follow-up period from July to September 2011, safety violations decreased to 42 violations per 100 doses — a decrease of nearly 50 percent. Medication administration errors decreased to 2.8 per 100 doses — a rate reduction of approximately 72.8 percent
The rate of compliance with all six safe practices and the absence of any of eight medication administration errors, called the "perfect dose" score, increased from 37 per 100 doses to 68 per 100.
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Virginia Mason Medical Center combined the Collaborative Alliance for Nursing Outcomes Medication Administration Accuracy Quality Study with Lean quality improvement strategies to improve medication safety. Lean techniques aimed to improve the medication room layout, apply visual controls and implement nursing standard work, according to the study.
Researchers analyzed improvement on six safe practices:
1. Comparing medication with medication administration record
2. Labeling medication
3. Checking two forms of patient identification
4. Explaining medication to patient
5. Charting medication immediately
6. Protecting the process from distractions/interruptions
Trained nurse auditors observed medication administration. At baseline — measured from January to March 2010 — there were 83 safe-practice violations per 100 doses and 10.3 medication administration errors per 100 doses. After the intervention, measured in a follow-up period from July to September 2011, safety violations decreased to 42 violations per 100 doses — a decrease of nearly 50 percent. Medication administration errors decreased to 2.8 per 100 doses — a rate reduction of approximately 72.8 percent
The rate of compliance with all six safe practices and the absence of any of eight medication administration errors, called the "perfect dose" score, increased from 37 per 100 doses to 68 per 100.
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