Project Title: Does systems thinking improve the perception of safety culture and patient safety? A medication administration education intervention. Project Overview This study was developed in response to a management level discussion concerning the downward trend of voluntarily reported medication errors. Patient safety and specifically reduction of medication administration errors is an organizational focus, and many believe that the number of errors has not decreased as markedly as what has been reported. Nursing leaders are concerned and want to identify if there are underlying reasons why medication errors may not be reported. For the proposed study, we will: 1) explore possible associations between systems thinking, safety attitudes, and voluntary reporting of medication errors; 2) identify possible workarounds used during medication administration that may lead to medication errors and affect patient safety; and 3) test the efficacy of a systems thinking education program (STEP) based on a pro-active, non-punitive, and interdisciplinary approach to improve patient safety. Purpose, Problem Statement or Research Question(s): The overall purpose of this project is to improve patient safety with respect to medication administration. The specific purpose of this project is to evaluate an education intervention based on systems thinking. Approximately 1.5 million preventable adverse drug events occur annually in the United States and patients in the Midwest are at increased risk due to the highest reported rates compared to any other region. Many of these adverse drug events are due to administration errors (Weis & Elixhauser, 2013). Errors involving high-alert medications, such as opiates, anticoagulants, and insulin, are of special concern as the patient outcomes can be devastating (Graham, 2008). Independent double check of high-alert medications is believed to decrease

medication errors, but whether or not nurses follow this protocol is usually unknown. Despite new technologies such as barcode medication administration (BCMA), electronic medication administration records (eMAR), and computerized provider order entry (CPOE), observational studies have shown that workarounds to known medication policies are common (Carayon, 2007; Koppel, Wetterneck, Telles, & Karsh, 2008;). While workarounds may be used to be more efficient and expedient in medication administration, this practice also increases risk for error (Poon, et al. 2010; Koppel, Wetterneck, Telles, & Karsh, 2008). Nurses’ self reporting of medication errors has been specifically associated with their perception of the safety culture of the organization (Kagan & Barnoy, 2013).

Safety culture is

characterized by a blame-free environment, interdisciplinary collaboration to seek solutions, consistent adherence to evidence-based policies, and leadership’s commitment to prioritize resources for safety concerns (AHRQ, 2012). When medication errors do occur, it is important to identify why nurses acted as they did and the relationship between their behavior and their perceptions of the health care system environment, instead of what went wrong (Armitage, 2009). While learning from medication errors needs to occur at the individual, unit/clinic, and organization levels, systems based practice is not typically emphasized in most nursing programs. Nurses have been educated to recognize personal responsibility, but may not appreciate how safety culture influences their individual behavior. In order to engage nurses in systems thinking, it is important that they view problems as part of a chain of events of a larger system, rather than independent events (Dolansky & Moore, 2013). This study will incorporate observation audits of the medication administration process, including high-alert medications, in both the inpatient and ambulatory care settings. Process improvement interventions that encourage reporting of medication errors through medication

huddles, collaborative development of organization solutions, and avoidance of individual blame, all of which help front-line staff use systems thinking, will be implemented. Specifically, this study aims to: 1.

Identify workarounds nurses employ during the medication administration process.

2. Test the efficacy of a systems thinking education program to reduce workarounds that jeopardize patient safety. H1: The frequency of nurse workarounds during medication administration will decrease after the systems thinking education program. 3.

Explore the relationship among perceptions of safety culture, systems thinking and medication errors. H2: Nurses perception of safety culture will become more positive after the systems thinking education program. H3: Systems thinking will be positively correlated with the perception of safety culture. H4: With an increase in perception of safety culture there will be a simultaneous increase in voluntary reporting of medication errors.

As of February 2016: The initial survey found that systems thinking was positively correlated with the perception of safety culture. The STEP program has been completed. The post survey of Patient Safety Culture and Systems Thinking has been administered and data has been collected. The post intervention medication administration observation is currently being conducted.

References Agency for Healthcare Research and Quality (AHRQ) (2012). Patient Safety Primer: Safety Culture. Retrieved from http://psnet.ahrq.gov/printviewPrimer.aspx?primerID=5 Armitage, G. (2009). The risks of double checking. Nursing Management, 16(2), 30-35. Carayon, P., Wetterneck, T. B., Hundt, A. S., Ozkaynak, M., DeSilvey, J., Ludwig, B., …Rough, S. S. (2007). Evaluation of nurse interaction with bar code medication administration technology in the work environment. Journal of Patient Safety, 3(1), 34-42. Dolansky, M. A., & Moore, S. M. (September 30, 2013). Quality and safety education for nurses (QSEN): The key is systems thinking. OJIN: The Online Journal of Issues in Nursing, 18(3), Manuscript 1.

Graham, S., Clopp, M. P., Kostek, N. E., & Crawford, B. (2008). Implementation of a high-alert medication program. The Permanente Journal, 12(2), 15-22.

Kagan, I., & Barnoy, S. (2013). Organizational safety culture and medical error reporting by Israeli nurses. Journal of Nursing Scholarship, 45, 273-280. Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal American Medical Informatics Association, 15, 408-423. Poon, E. G., Keohane, C.A., Yoon, C. S., Ditmore, B. A., Bane, A., Levtzion-Korach, O., Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362, 1698-1707. Weiss, A. J., & Elixhauser, A. (2013). Characteristics of adverse drug events originating during the hospital stay, 2011. HCUP Statistical Brief #164. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbrief/sb164.pdf