Using an Educational Module and Simulation Learning Experience to Improve Medication Safety

<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>

Name thesis:degree_name

Doctor of Nursing Practice (DNP)

Level thesis:degree_level

Project

Discipline thesis:degree_discipline

Nursing

Year dc:date.available

2014

Author dc:creator

• Durham, Barbara Lynn

Contributors dc:contributor

• KT Waxman
• Juli Maxworthy
• Janeen Whitmore

• Medication safety education
• medication errors
• near miss events
• simulation
• patient-controlled analgesia
• quality improvement
• Other Nursing

Repository record dc:identifier

https://repository.usfca.edu/dnp/42

OAI identifier oai:identifier

oai:repository.usfca.edu:dnp-1053