Slide 1: Quality Improvement Presentation Poster Learner’s Name University Evidence-Based Practice for Patient-Centered Care and Population Health Evidence-Based Practice Implementation Plan April, 2022
Background on Clinical Problem
Increase in medication errors among admitted children
Nurses have reported that they have mistakenly issued the wrong medication doses, and in other cases, confused the medications and the patients.
Medication errors among the admitted children occur three times more frequently than in adults (Feyissa et al., 2020).
Medication errors are the most common cause of adverse events in pediatrics (D'Errico et al., 2022)
Stakeholders
Pediatric nurses
Intensivists
Clinical pharmacists
Hospital executives
Quality Improvement (QI) & patient safety teams
IT & informatics specialists
Potential Barriers
D'Errico, S., Zanon, M., Radaelli, D., Padovano, M., Santurro, A., Scopetti, M., ... & Fineschi, V. (2022). Medication errors in pediatrics: proposals to improve the quality and safety of care through clinical risk management. Frontiers in Medicine, 8, 814100. https://doi.org/10.3389/fmed.2021.814100
Feyissa, D., Kebede, B., Zewudie, A., & Mamo, Y. (2020). Medication Error and Its Contributing Factors Among Pediatric Patients Diagnosed with Infectious Diseases Admitted to Jimma University Medical Center, Southwest Ethiopia: Prospective Observational Study. Integrated pharmacy research & practice, 9, 147–153. https://doi.org/10.2147/IPRP.S264941
Hosseini, M. S., Jahanshahlou, F., Akbarzadeh, M. A., Zarei, M., & Vaez-Gharamaleki, Y. (2024). Formulating research questions for evidence-based studies. Journal of medicine, surgery, and public health, 2, 100046. https://doi.org/10.1016/j.glmedi.2023.100046
Sabzi, Z., Mohammadi, R., Talebi, R., & Roshandel, G. R. (2019). Medication Errors and Their Relationship with Care Complexity and Work Dynamics. Open access Macedonian journal of medical sciences, 7(21), 3579–3583. https://doi.org/10.3889/oamjms.2019.722
Tu, H. N., Shan, T. H., Wu, Y. C., Shen, P. H., Wu, T. Y., Lin, W. L., ... & Cheng, C. L. (2023). Reducing medication errors by adopting automatic dispensing cabinets in critical care units. Journal of medical systems, 47(1), 52. https://doi.org/10.1007/s10916-023-01953-0
Yalçın, N., Kaşıkcı, M., Çelik, H. T., Allegaert, K., Demirkan, K., Yiğit, Ş., & Yurdakök, M. (2023). Development and validation of a machine learning-based detection system to improve precision screening for medication errors in the neonatal intensive care unit. Frontiers in pharmacology, 14, 1151560. https://doi.org/10.3389/fphar.2023.1151560
Outcome Measures
Resistance to change
Resources constraints
Lack of skills and knowledge
Time
Current Medication Errors Data: 20
Medication Errors data at 1 month: 15
Medication Errors 3 months:10
Medication Errors at 6 months: 0
PICOT Question
P: In hospitalized children admitted to the pediatric ward
I: Does the implementation of evidence-based practices
C: compared to routine practices
O: reduce medication errors
T: during hospitalization or within 6 months of implementation
Action Plan
Practice change: implementation of a computerized provider order entry system paired with the real-time barcode medication administration (BCMA).
Timeline: 6 months
Tools or resources: wireless barcode scanners, unified communication devices, point-of-care devices, thermal barcode printers, clinical informatics specialists, and software & integration resources.
Quadruple Aim
References
Patient experience
Population health
Reduce healthcare costs
Health care provider work life