Pain medication management : a quality improvement DNP project

Problem: Medication administration errors (MAEs) related to pain management remain a significant patient safety concern in hospital settings. A safety event involving opioid overmedication requiring naloxone at a community hospital prompted a root cause analysis. Findings identified inconsistent prescribing practices and absence of standardized pain medication order sets, contributing to variability in care and increased risk for pain-related MAEs. Purpose: The purpose of this quality improvement project was to reduce pain MAEs in hospitalized adults through implementation of a standardized, evidence-based pain medication order set. Methods: Using the Plan-Do-Study-Act (PDSA) framework, a standardized multimodal pain medication order set was implemented across six medical/telemetry units in a mid-Atlantic community hospital. The intervention incorporated multimodal analgesia strategies that were tied to admission order sets to promote safe prescribing practices. Baseline MAE data from the organization's event reporting system were compared with post-implementation data during a six-week implementation period. Results: Implementation of the standardized pain medication order set reduced pain MAEs from 38 events during the six-week baseline period to 24 events during the six-week implementation period, representing a decrease in 14 events. Additionally, overall event reporting increased, the proportion of pain-related MAEs decreased, suggesting improved medication safety and strengthened reporting culture. Conclusion: The implementation of a standardized, evidence-based pain medication order set was associated with a reduction in pain MAEs and improved prescribing consistency. These findings support structured order sets as a system-level strategy to promote safe and effective pain management.

Author dc:creator

• Zern, Kasey

Contributors dc:contributor

• Foster, Mariah

• Hospitals--Drug distribution systems
• Medication errors--Prevention
• Pain medicine--Administration

Statement dc:rights

• In Copyright

Language dc:language

English

Identifier

dnp:93
oclc:1601633830
local:R_3oRE9VNbxIYYdtw

OAI identifier oai:identifier

oai:d.lib.msu.edu:dnp_93