Authors (including presenting author) :
Lai YW (1), Cheung MY (1), Cheung MYD (1),Ho MF (1), Yan YPK (1), Chan WK (1), Lam CP (1), Leung SK (1)
Affiliation :
(1)Central Nursing Division, Kwong Wah Hospital
Introduction :
Medication Incidents (MI) can occur anywhere along the pathway from prescription, dispensing to administration, but “Administration of Medication (AOM)” errors by nurses are the most common. In Kwong Wah Hospital (KWH), we carried out two years in-depth study of AOM related to MI, from June 2017 to May 2019, with 56 cases in total. Analysis showed that 75% of the cases involved experienced nurses. Majority causes of errors were related to non-technical skill domain, including communication, leadership or decision making. In response to this study, KWH developed a ‘Non-technical Skills (NTS) Simulation Training Program’ to enhance medication safety, which targeted clinical nurses with 10 years experiences or above. Skills in communication, team work, analytical and personal behavior were focused.
Objectives :
1) Rebuild experienced nurses’ conceptualization of medication safety 2) Reinforce the influencing role of nurses on prevention of MI 3) Strengthen the staff commitment by self-actualization model
Methodology :
This program was a half day workshop with three parts in design. Part one was a simulated clinical scenario of AOM related activities, with immediate debrief. Part two involved an extended debriefs and facilitates discussion on selected MI related videos. Understanding human limitations and how they could affect happen of medication incidents were also being addressed. In part three, specific skills of communication, assertion and situational awareness were encouraged to be practiced during the workshop. “The Wishing-Tree” gimmick for “Zero – MI Incident” was incorporated to sustain participants’ commitment to MI prevention.
Result & Outcome :
Four identical workshops were rolled out in 2Q 2019, then followed by a six months MI cases review evaluation from July 2019 to December 2019. Findings showed a downward trend of case numbers from biannual 14 cases to 9 cases, in which 7 cases involved experienced nurses’. Due to the limitation of data, this review was not statistically significant, but these four workshops inspiring us that communication, leadership and decision making should be the determinant skills for MI tackling. This NTS simulation program created impact and desired behaviors for positive practice change in medication administration. It is impossible to eliminate all medication incidents, but patient safety must always being the utmost concern for nurses.
