The purpose of this evidence-based change in practice project was to provide nurses with an experiential learning opportunity, using simulation, to identify and report near miss events during the medication administration process related to patient-controlled analgesia (PCA) usage. Despite extensive in-service training on a Medical/Surgical (Med/Surg) floor in an acute care hospital, inconsistent, inaccurate and incomplete documentation with use of the new PCA pumps continued to be problematic. A conceptual framework of just culture was used with the quality improvement method of the Plan-Do-Study-Act (PDSA) cycle for testing change. Medication safety education was a valid andragogical strategy to decrease rates of medication errors and improve patient outcomes by identifying complex system issues that interfered with safe practices. The education program consisted of a series of self-learning modules, definitions of near miss events and medication errors; in addition a simulation learning experience was included. A needs assessment was conducted to help determine gaps in practice. Results of the survey demonstrated inconsistencies in the current practice of documenting vital signs on patients with a PCA in contrast to the existing policy and procedure; these results were shared with the staff nurses at a staff meeting and via email. Although no changes in care delivery were directly observed, the doctorate of nursing practice (DNP) student was able to reinforce the documentation requirements per the hospital’s policy.
","abstract_html":"<p>The purpose of this evidence-based change in practice project was to provide nurses with an experiential learning opportunity, using simulation, to identify and report near miss events during the medication administration process related to patient-controlled analgesia (PCA) usage. Despite extensive in-service training on a Medical/Surgical (Med/Surg) floor in an acute care hospital, inconsistent, inaccurate and incomplete documentation with use of the new PCA pumps continued to be problematic. A conceptual framework of just culture was used with the quality improvement method of the Plan-Do-Study-Act (PDSA) cycle for testing change. Medication safety education was a valid andragogical strategy to decrease rates of medication errors and improve patient outcomes by identifying complex system issues that interfered with safe practices. The education program consisted of a series of self-learning modules, definitions of near miss events and medication errors; in addition a simulation learning experience was included. A needs assessment was conducted to help determine gaps in practice. Results of the survey demonstrated inconsistencies in the current practice of documenting vital signs on patients with a PCA in contrast to the existing policy and procedure; these results were shared with the staff nurses at a staff meeting and via email. Although no changes in care delivery were directly observed, the doctorate of nursing practice (DNP) student was able to reinforce the documentation requirements per the hospital’s policy. </p>","abstract_has_math":false,"creators":["Durham, Barbara Lynn"],"institution":null,"degree_name":"Doctor of Nursing Practice (DNP)","degree_level":"Project","degree_discipline":"Nursing","degree_department":null,"school":null,"contributors":["KT Waxman","Juli Maxworthy","Janeen Whitmore"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2014,"date_issued":"2014-12-12T08:00:00Z","date_published":"2014-12-12T08:00:00Z","updated_at":"2026-07-24T05:42:56Z","subjects":["Medication safety education","medication errors","near miss events","simulation","patient-controlled analgesia","quality improvement","Other Nursing"],"languages":[],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://repository.usfca.edu/dnp/42","outbound_label":"Repository record","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["KT Waxman","Juli Maxworthy","Janeen Whitmore"]},{"key":"dc:creator","label":"Author","values":["Durham, Barbara Lynn"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.available","label":"Dc Date Available","values":["2014-12-03T08:00:00Z"]},{"key":"thesis:degree_discipline","label":"Discipline","values":["Nursing"]},{"key":"thesis:degree_level","label":"Degree Level","values":["Project"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Doctor of Nursing Practice (DNP)"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Medication safety education","medication errors","near miss events","simulation","patient-controlled analgesia","quality improvement","Other Nursing"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://repository.usfca.edu/dnp/42"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["The purpose of this evidence-based change in practice project was to provide nurses with an experiential learning opportunity, using simulation, to identify and report near miss events during the medication administration process related to patient-controlled analgesia (PCA) usage. Despite extensive in-service training on a Medical/Surgical (Med/Surg) floor in an acute care hospital, inconsistent, inaccurate and incomplete documentation with use of the new PCA pumps continued to be problematic. A conceptual framework of just culture was used with the quality improvement method of the Plan-Do-Study-Act (PDSA) cycle for testing change. Medication safety education was a valid andragogical strategy to decrease rates of medication errors and improve patient outcomes by identifying complex system issues that interfered with safe practices. The education program consisted of a series of self-learning modules, definitions of near miss events and medication errors; in addition a simulation learning experience was included. A needs assessment was conducted to help determine gaps in practice. Results of the survey demonstrated inconsistencies in the current practice of documenting vital signs on patients with a PCA in contrast to the existing policy and procedure; these results were shared with the staff nurses at a staff meeting and via email. Although no changes in care delivery were directly observed, the doctorate of nursing practice (DNP) student was able to reinforce the documentation requirements per the hospital’s policy.
"]},{"key":"dc:title","label":"Title","values":["Using an Educational Module and Simulation Learning Experience to Improve Medication Safety"]}]}],"canonical_facts":{"dc:contributor":["KT Waxman","Juli Maxworthy","Janeen Whitmore"],"dc:creator":["Durham, Barbara Lynn"],"dc:date.available":["2014-12-03T08:00:00Z"],"dc:description.abstract":["The purpose of this evidence-based change in practice project was to provide nurses with an experiential learning opportunity, using simulation, to identify and report near miss events during the medication administration process related to patient-controlled analgesia (PCA) usage. Despite extensive in-service training on a Medical/Surgical (Med/Surg) floor in an acute care hospital, inconsistent, inaccurate and incomplete documentation with use of the new PCA pumps continued to be problematic. A conceptual framework of just culture was used with the quality improvement method of the Plan-Do-Study-Act (PDSA) cycle for testing change. Medication safety education was a valid andragogical strategy to decrease rates of medication errors and improve patient outcomes by identifying complex system issues that interfered with safe practices. The education program consisted of a series of self-learning modules, definitions of near miss events and medication errors; in addition a simulation learning experience was included. A needs assessment was conducted to help determine gaps in practice. Results of the survey demonstrated inconsistencies in the current practice of documenting vital signs on patients with a PCA in contrast to the existing policy and procedure; these results were shared with the staff nurses at a staff meeting and via email. Although no changes in care delivery were directly observed, the doctorate of nursing practice (DNP) student was able to reinforce the documentation requirements per the hospital’s policy.
"],"dc:identifier":["https://repository.usfca.edu/dnp/42"],"dc:subject":["Medication safety education","medication errors","near miss events","simulation","patient-controlled analgesia","quality improvement","Other Nursing"],"dc:title":["Using an Educational Module and Simulation Learning Experience to Improve Medication Safety"],"thesis:degree_discipline":["Nursing"],"thesis:degree_level":["Project"],"thesis:degree_name":["Doctor of Nursing Practice (DNP)"]},"updated_at":"2026-07-24T05:42:56Z"}