The North Dakota Nurses - January 2022

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Page 12 The North Dakota Nurse January, February, March 2022 Factors Influencing Medication Errors Anna Holen, Abby Seifert, & Christine Vetsch BSN Students, University of Jamestown Editor: Penny Briese, PhD(c), RN University of Jamestown Clinical Question: What are some factors that influence nurses’ medication errors? Medication safety is a priority for nurses, considering medication administration accounts for 40% of the nurse’s occupational duties and nurses “are responsible for 26- 38% of medication errors” (Dougal, 2020, p. 7). There are factors that influence and increase/decrease the chances of making medication errors. Being aware of these factors can promote medication safety and decrease the number of errors that are too prominently occurring in the nursing field. Six different articles related to medication errors in the nursing profession were included in this miniature literature review. In 2018, Treiber and Jones performed a quantitative study in an effort to understand individual and system level factors that contribute to medication errors from the perspective of BSN nursing graduates. The researchers investigated perceptions of adequacy of preparatory nursing education, contributory variables, emotional responses, and treatment by employers following the error (Treiber & Jones, 2018). The study consisted of 168 participants who completed an online survey. The survey was sent out to BSN graduates from Kennesaw State University in Georgia who graduated between the years of 2009-2013. Most of the participants were white (71%), female (89%), and nearly all were currently practicing nursing (Treiber & Jones, 2018). More than half of the respondents indicated they had made a medication error since becoming a registered nurse; a majority stated that when they made an error their facility was supportive. Reasons that a nurse did not report a medication error included fear of repercussion, perception the error was not serious, and the process to report the error being too time consuming (Treiber & Jones, 2018). Bekes, Sackash, Voss, and Gill (2021) focused their study on medication errors seen specifically in pediatric patients in the perioperative period. The researchers sought to answer two main questions: 1) what are the main types of medication errors in the pediatric population in the perioperative period, and 2) what mitigation strategies had the best outcome that can be incorporated into practice? This was a narrative literature review of 17 articles. The inclusion criteria for this review included a patient population from one to 18 years of age, articles printed in the English language, full-text publications, and focused on perioperative periods of care (Bekes et al., 2021). The researchers scored each article using the critical appraisal skills program qualitative checklist because it breaks down the methodological approach to determine the quality of each article. They found that the most frequent errors mentioned in the multiple research studies were incorrect doses (77%) including dilution errors, calculation errors, and incorrect intervals. Other examples of common medication errors included incorrect medication, grabbing the incorrect syringe, inappropriate medication labeling, and giving a known allergen (Bekes RECENTLY INCREASED WAGES Full or Part Time RN or LPN For More Information Contact Kasey Brandenburger, RN DON kasey.brandenburger@stgerards.org 701-242-7891 St. Gerard’s Community of Care Hankinson, ND Stgerards.org et al., 2021). The researchers concluded by discussing interventions that reduce medication errors which entailed standardized labeling, prefilled syringes, two-person checks, drug library/ electronic-based references, quality improvement safety analytics, pharmacy support, computer check systems, staff education, standardized workspace, zerotolerance philosophy, and checklists (Bekes et al., 2021). Ragau, Hitchcock, Craft, and Christensen (2018) wanted to look specifically at the individual human factors that can cause medication errors. They used the HALT model (hungry, angry, late, lonely, and tired) to try and reduce the incidence of medication errors by 25% by allowing nurses to “be more aware of how their emotional behavior may have a deleterious effect” on medication administration (Ragau et al., 2018, p. 1333). The HALT model was implemented in a 32-bed acute medical unit. ‘HALT’ posters were placed throughout the unit to remind the team to “effectively ‘HALT’ and take time to reflect on what was occurring for them on an emotional level and then take the appropriate action” (Ragau et al., 2018, p. 1333). The model was also used during shift hand-off to highlight any emotions that needed to be addressed before the shift change. After the implementation of the HALT model, there was a decrease in total medication errors by 31.7% over a two-month period, a 25.3% decrease in errors relating to human error, and a 22.9% decrease in communication and documentation-related errors (Ragau et al., 2018, p. 1334). Although this study had a positive response, “caution should be used when addressing other contributing factors associated with medication errors as using HALT alone will not address these” (Ragau et al., 2018, p. 1334). Berdot et al. (2021) conducted a study on nurses wearing a special vest indicating a time of requested un-interruption. They analyzed whether the introduction of the vest reduced medication errors during medication administration. This was a multicenter, randomized controlled trial performed in 29 adult units in four hospitals. Over the course of the study, 178 nurses in 14 units wore a ‘do not interrupt’ vest during 383 observed medication rounds to examine the main outcome of administration error rate. The error rate was defined as “number of Opportunities for Error, OE, calculated as one or more errors divided by the Total Opportunities for Error, TOE, multiplied by 100” (Berdot et al., 2021, p. 1). Berdot et al. (2021) found that the administration error rates in the experimental group was 7.09% and 6.23% in the control group (p. 1). The interruption rates were also similar, with the experimental group being 15.04% and the control group being 20.75% (Berdot et al., 2021, p. 6). These results indicate that the “vest had no impact on medication administration error or interruption rates” (Berdot et al., 2021, p. 6). Dougal (2020) conducted a quantitative nonexperimental study to determine the perception of medication administration and medication errors from registered nurses, related to the risks, benefits, frequency, and cautions associated with it. The researcher had three research questions; 1) do nurses perceive risk in medication administration in everyday practice, 2) how is an RN’s self-reporting behavior related to medication administration errors and risks, and 3) do nurses perceive benefit and risk to medication safety during the administration process? (Dougal, 2020) This study surveyed 1,445 RN’s using an online seven-point Likert scale questionnaire. Most RNs reported that they were “not at all likely” to report medication errors and believed they do not make errors in medication administration or are “unlikely” to do so within the next 12 months (Dougal, 2020, p. 9). They believe their peers were “very likely” to make errors in medication administration within the next 12 months (Dougal, 2020, p. 9). Most RNs in this study reported not following proper medication administration processes due to self-reported distractions, interruptions, and multi-tasking. Ekkens and Gordon (2021) conducted a quantitative quasi-experimental study to determine if adding mindfulness thinking to current protocol will eliminate or minimize medication errors. This study consisted of 111 nurses from rural hospitals located in northern California. The treatment group in this study received an intervention of mindfulness training while the control group did not receive training. “The instrument used for the study was based on the medication error index from the NCC MERP” (Ekkens et al., 2021, p. 119). This instrument is designed to categorize medication errors into nine levels of severity, each level corresponding to mild, moderate, significant, or severe severity. The researchers found that in the treatment group, errors were reduced from 15 to four, whereas the control group showed a reduction in errors from seven to six. The result from this study concludes that “nurses are not consistently mindful enough when administering medications; this contributes to errors” (Ekkens and Gordon, 2021, p. 120). Mindful thinking and effective training may help to reduce errors and help nurses focus on the task at hand. Conclusion There are many factors that can contribute to medication errors, but in return there are many interventions to help decrease the risk of errors and ensure patient safety. Medication errors have been studied extensively due to the danger that errors present to patient safety. The six articles summarized in this literature review support a numerous array of interventions that both feed into and can prevent medication errors. At an educational level, professors and mentors need to stress the importance of medication errors and prepare students for clinical experiences. New nursing graduates mentioned they should have had more hands-on experience with medication administration, especially IV, and time management skills to encourage effective care management (Treiber & Jones, 2018). It is highly recommended that even experienced nurses should always go through the medication rights such as correct dose, time, patient, route, refuse, and medication. Nurses should not be afraid to question doses that seem odd and they should not solely rely on technology to recognize mistakes. Facilities should support nurses in the field because, although reporting the error can be intimidating, reporting can help nurse administrators recognize systematic problems. Not all interventions are helpful and nurses often blame themselves for medication errors and feel guilty regardless of whether or not the error harmed the patient. Hospitals must find what works best for their individual nurses because the reasons for medication errors are quite individualized. Medication errors and safety continue to be a growing concern in the healthcare profession. References Bekes, J.L., Sackash, C.R., Voss, A.L., & Gill C.J. (2021). Pediatric medication errors and reduction strategies in the perioperative period. AANA Journal 89(4), 319-324. Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny…Sabatier, B. (2021). Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. BMC Nurs, 20(153), 1-11. doi: 10.1186/s12912-021-00671-7 Dougal, R.L. (2020). RN perceptions of medication administration and medication errors: Results from a quantitative nursing research study. RN Idaho, 43(1), 7-9. Ekkens, C. L. and Gordon, P. A. (2021). The mindful path to nursing accuracy: A quasi-experimental study on minimizing medication administration errors. Holistic Nursing Practice, 35(3), 115-122. doi: 10.1097/HNP.0000000000000440. Ragau, S., Hitchcock, R., Craft, J., & Christensen. (2018). Using the HALT model in an exploratory quality improvement initiative to reduce medication errors. British Journal of Nursing, 27(22). 1330-1336. doi: 10.12968/ bjon.2018.27.22.1330 Treiber, L.A. & Jones, J.H. (2018). After the medication error: Recent nursing graduates’ reflections on adequacy of education. Journal of Nursing Education, 57(5), 275-280. doi:10.3928/01484834- 20180420-04
January, February, March 2022 The North Dakota Nurse Page 13 Reducing Central Line-Associated Bloodstream Infections Ali Glynn, Amber Domres, & Hayley Johnson BSN students, University of Jamestown Editor: Penny Briese, PhD(c), RN University of Jamestown Clinical Question: What are the current best practices for preventing central line-associated bloodstream infections (CLABSI)? Bloodstream infections of central venous access lines are occurring at unacceptable levels in practice (Conwell, Ghidini, Perazella, Aniskiewicz, DeVaux, & Giullian, 2019). There are ways in which healthcare professionals can increase the safety of patients and improve care to reduce mortality risk. This miniature literature review will describe the evidence and best practices recommendations of six research studies focusing on central line-associated bloodstream infections (CLABSI). In one quantitative study, medical professionals at Yale New Haven Hospital in Connecticut evaluated their hemodialysis unit for the occurrence of CLABSI (Conwell et al., 2019). Observations within their dialysis unit showed that a central line infection occurred at a rate of 0.39%, however, of those with an acquired infection “mortality following a CLABSI ranged from 12-25%” (Conwell et al., 2019, p. 587). The implementation plan of their study included “a list of findings evident upon admission that could trigger further evaluation for infection early in the course of hospitalization” (Conwell et al., p. 588). Dressing changes were required to be documented, registered nurses were retrained on caring for central lines and were tested with new competencies to prove understanding. Research showed “the number of CLABSI events was notably lower following implementation of the program as over 2,280 treatments were performed on 382 patients in 2017 and no CLABSIs occurred” (Conwell et al., p. 588-589). The researchers concluded by reiterating the importance of prevention of central line infections in order to prevent lengthy hospital stays, high costs, and reduce mortality. One intervention commonly used in practice to decrease the risk of CLABSI is using chlorhexidine gluconate (CHG) bathing for infection prevention. Reynolds, Woltz., Keating, Neff, Elliott, Hatch, Yang, & Granger (2021) performed an academic and community-based study with 1,640 participants from hospital units who had at least 1 CLABSI event in the last year. All patients with a central line were given a CHG antimicrobial bath throughout the course of their treatments. Results showed that the units reported a decrease in patient stay of 1.67 days along with a 27.4% reduction in rates of CLABSI (Reynolds et al., 2021). Part of the intervention also included educational outreach to all members of the health care team regarding the purpose of the CHG bath, which generated this very positive outcome. In another study, five hospitals were evaluated between the years of 2013 and 2015 for CLABSI and their association with lines being “manipulated by healthcare workers and patients” (Sheth, Trifan, Feterik, & Jovin, 2017, 2017, p. 217). The incidence of CLABSIs has been reduced thruogh the implementation of CDC CLABSI prevention bundles; however, manual manipulation of lines are also suspected to be a cause of infection. During this study, 30 CLABSI events were reported and 16 of these events had noted “line manipulation 48-72 hours prior to infection” (Sheth et al., 2017, p. 217). Manipulation of the line includes flushing the line, administering fluids and medications. Overall, this study concluded that CLABSI prevention bundles helped reduce the number of CLABSIs, but more interventions are needed to reduce infections related to central line manipulation. Suttle Buffington, Madden, & Dawson (2019) studied 85 participants in a 29-bed hematology oncology specialty unit at the University of Alabama at Birmingham Hospital. The study included “patient engagement and empowerment” to reduce infections of central lines (Suttle et al., 2019, p. 10). The independent variable of this study was the implementation of the EPIC bundle, which included an “educational video, poster, patient silicone bracelet and a nursing staff sticker” (Suttle et al., 2019, p. 12). The dependent variable was the prevalence of CLABSIs. Two factors were found to interfere with patient education: 1) health care workers feeling unsure of just how much responsibility to place on patients, and 2) patients not wanting to bother healthcare workers and ask them to wash their hands. The intervention of the EPIC bundle reduced the number of infections by “46% within eight weeks” (Suttle et al., 2019. p. 11). The results of this study showed that, overall, following implementation of the EPIC bundle, patients felt more empowered and in control of their care leading to a reduction of CLABSIs. Another study done by Wilder, Wall, Haggard, & Epperson (2016) assessed the effectiveness of integrating central-line principles and a team-based approach into CLABSI reduction in neonatal intensive care units. This study aimed to reduce CLABSI rates by the implementation of a line-rounding tool (Wilder et al., 2016). The line-rounding included small dedicated CLABSI prevention teams who took over doing peripherally inserted central catheter (PICC) dressing changes with a specified technique, while including training opportunities for other neonatal nurse practitioners. The study showed an improvement in CLABSI rates by 93% (Wilder et al., 2016). The reduction in CLABSI rates was accompanied by reduced patient harm, reduced length of stay and costs. The research concluded that implementing line-rounding teams, raising awareness of a “safety-first culture”, along with a multidisciplinary team approach to central line maintenance can make a significant impact on CLABSI rates. And finally, in discussing multidisciplinary team approaches in CLABSI reduction, the final study reviewed showed significant findings with the integration of collaborating care teams in achieving reduced CLABSI rates (p < 0.05). Evidence-based practices were discussed in the article but so were new technologies like “disinfecting caps and needleless securement devices” (Layne & Anderson, 2019, p. 285). In this study, a hospital multidisciplinary team wanted to address central line practices that were occurring. Their findings of their assessment were based on two components of prevention: dressing maintenance and caregivers’ critical skills (Layne et al., 2019, p. 285). The collaborative team also identified that two critical skills in particular needed improvement; dressing changes and blood draws. The team used these findings to initiate central line maintenance skills re-education for practicing nurses and found rapid improvements in securement and dressing maintenance and there was a 57% reduction in CLABSI occurrences in the fiscal year 2016 to 2017 (Layne et al., 2019). Conclusion The incidence of CABSI remains high in healthcare today. It is imperative that healthcare providers continue to search the literature for best practices. The findings of this miniature literature review indicate that the use of admission checklists, antiseptic bathing, patient empowerment, patient care bundles, and multidisciplinary team approaches and reeducation are all integral practices associated with the reduction of CLABSI in the hospital settings. References Conwell, R., Ghidini, J., Perazella, M., Aniskiewicz, M., DeVaux, L., & Giullian, J. (2019). A hospital-based program to reduce central line-associated bloodstream infections among hospitalized patients receiving hemodialysis using a central venous catheter for vascular access. Nephrology Nursing Journal, 46(6), p. 587-592. Layne, D. M., & Anderson, T. (2019). A collaborative approach to reducing Central line-associated bloodstream infections. Journal of Nursing Care Quality, 34(4), 285–286. https://doi.org/10.1097/ncq.0000000000000419 Reynolds, S.S., Woltz, P., Keating, E., Neff, J., Elliott, J., Hatch, D., Yang, Q., & Granger, B. (2021). Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections study (CHanGing BathS): a stepped wedge cluster randomized trial. Implementation Science, 45(16), p. 1-16. Doi: 10.1186/s13012-021-01112-4 Sheth, H., Trifan, A., Feterik, K., & Jovin, F. (2017). Expanding central line care bundle to address line manipulations. Canadian Journal of Infection Control, 32(4), 217–221. Suttle, R. D., Buffington, H. M., Madden, W. T., & Dawson, M. A. (2019). Central Line Care: Empowering patients to prevent infection and injury via EPIC². Clinical Journal of Oncology Nursing, 23(1), E10–E16. https://doi.org/10.1188/19.CJON. E10-E16 Wilder, K. A., Wall, B., Haggard, D., & Epperson, T. (2016). A systemic central line quality improvement initiative integrating line-rounding principles and a team approach. Advances in Neonatal Care, 16(3), 170-177. https://doi. org/10.1097/anc.0000000000000311 The ongoing COVID pandemic has made it difficult for people to maintain their mental health and well-being. Developed in 2019, the North Dakota Community Clinical Collaborative (NDC3) is helping communities across North Dakota create a culture of health, where prevention and wellness are the norm. NDC3 houses programs that provide education, fitness instruction, and self-care strategies for participants; they do not replace clinical care provided by doctors, nurses, and other medical professionals. NDC3 also provides the ability for caregivers and health care providers to refer loved ones or patients to appropriate programs. Through partnerships across the state, NDC3 connects evidence-based health management activities that promote health and prevent disease to adults with or caring for people with chronic health conditions. These programs have been developed using rigorous research and demonstrate reliable and consistently positive changes in health-related outcomes among participants. Lisa Thorp, BSN, CDCES wrote: “I was recently visiting with colleagues about the availability of certain services across the state. Often, it appears that there are more services available on the eastern side of the state. NDC3 helps level the playing field by organizing the information of virtual classes that are available. As a Certified Diabetes Care and Education Specialist, I love the fact that people with diabetes can search NDC3 and find classes to help them better manage their diabetes. A search can be done to find a Diabetes Prevention class, or a Better Choices Better Health-Diabetes Class, and attend them virtually! In addition to diabetes classes, there are also other classes for chronic conditions and pain, and strengthening, which can help reduce falls in the home. I encourage other nurses, diabetes educators, primary care providers to use the referral option. Provide the patient contact information and they will get called to help them find a class. Check out Connecting you to community health programs - NDC3! Feel free to contact me for questions at lisa.thorp@ greatplainsqin.org”
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