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Essay: High-reliability / medication safety / medication reconciliation

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Since we started our journey to high-reliability in 2015 I became passionate about patient safety. Falls, hospital-acquired infections, hospital-acquired pressure ulcers, and medication safety result in patients being harmed in the care of healthcare professionals. Medication reconciliation seems like a straight-forward process. The average person’s thought process is the patient comes in the hospital, the nurse asks the name of the medications, the nurse documents that information and the medications are reconciled. “However, the process of gathering, organizing, and communicating medication information across the continuum of care is not straightforward.” (Barnsteiner, 2008, Chapter 38) Gathering medication lists come from multiple sources-patient, family, physicians, pharmacist, and nurses-which begs the question “Who is the source of truth?”

The challenge in our organization is the accuracy of medication history. The patient arrives at the hospital in a vulnerable state. Patients who come in through the emergency department (ED) did not plan the current circumstances. This emotional trauma results in unintentional forgetfulness. All members of the healthcare team are challenged in the gathering of accurate medication history.

Kurt Lewin’s change theory is an effective change theory. Unfreezing prepares for change. (Shirey, 2013). During the second stage the change process occurs, followed by the third stage of refreezing the change. (Shirey, 2013) The action plan for improving the medication history process involves allowing the stakeholders to see the need for change. If the leaders see the need but the frontline nurses do not see the need to change, no unfreezing will occur. “Creating a sense of urgency for change is part of the unfreezing.” (Shirey, 2013, para. 3)

As a leader, it is essential to come alongside the frontline nurse. One way we will implement this is to have the admit nurses from the observation unit shadow the ED nurse during the process of obtaining the medication history. We also plan on bringing the ED nurse to the observation unit to shadow the admit nurse on the unit and observe the process of obtaining the medication history. In my experience, this has the most powerful effect on frontline caregivers.

Moving into the 2nd stage of Lewin’s theory is understanding “change as a process rather than an event.” (Shirey, 2013, para. 4) The actions in the moving phase will include education to all the nurses in the ED. Currently, we complete an occurrence report on each incorrect medication history. We will use these reports as an educational source for the nurse involved in the process.

“Refreezing, the 3rd stage of the theory, demands stabilizing the change so that it becomes embedded into existing systems such as culture, policies, and practices.” (Shirey, 2013, para. 5) Refreezing will occur at different levels. Individual nurses may make changes in the practice but getting the masses to make refreeze is dependent on accountability and continued education.

The barriers to implementing this process are getting the ED nurses to agree to shadow the inpatient nurses. There is a perceived barrier between ED nurses and the inpatient nurses. Both sides of the fence believe they work harder than the other side. The leaders from the ED and the observation unit report to the same administrative director, which will encourage support.

The stakeholders are nurses, pharmacists, physicians, patients, and families. I have discussed the role of the nurses through this process. The pharmacists, especially in the ED, are stakeholders in this process since they participate in the medication history. Another stakeholder is the physicians. The current process allows the physician to approve medication reconciliation without the medication history being complete. Often times this allows errors to be made which reach the patient.

The resources required to facilitate this action plan include the ED leadership team, the inpatient leadership team, education department. and pharmacy. Once the education plan is implemented, this will become a house-wide initiative. Patients who enter the organization through other departments will require the same process for medication history details.

References

Barnsteiner, J. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses . Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2648/

Shirey, M. (2013, February). Lewin's Theory of Planned Change as a Strategic Resource. The Journal of Nursing Administration, 43, 69-72. http://dx.doi.org/10.1097/NNA.0b013e31827f20a9

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