Emergency Department Medication Safety: Error Prevention and Procedure Review

🔎 Background:

Our team received an urgent request from nursing leadership in the Emergency Department. A review of data and trends identified several concerning events related to medication safety, revealing a need for additional education. During our initial meetings, additional safety events related to the wasting of narcotics occurred. This elevated the priority of the project and moved the timeline up significantly.

🎯Aims:

• Recognize the correlation between medication safety best practices and harm prevention.

• Review the Six Rights of medication administration.

• Explain the procedure for labeling and handling medications.

• Describe the expected practice and process for controlled substance administration, return, and wasting.

• Define diversion, recognize what diversion behaviors may look like, and reinforce the serious implications associated with diversion.

💡 Methods:

Using content provided by the subject matter experts, I designed a storyboard and presented a plan for an e-learning module. The content was segmented into short, digestible chunks and featured many interactive elements. Multiple types of media were incorporated, and the focus was on presenting information in a logical, relevant way.

• Medication Safety in the ED - A brief video highlighted some of the safety events that occurred, providing context for this education.

• Medication Administration Best Practices - This lesson reviewed the Six Rights of Medication Administration, proper labeling and handling of medications, and beyond use date/expiration information. Methods included interactive clickables, such as post-it notes, flip cards, and more.

• Administration and Wasting of Narcotics - This segment highlighted controlled substance administration, return, and wasting.- Using pictures of the ED’s medication room and equipment, this lesson required learners to click through and follow the correct procedure for administering and wasting narcotics.

• Diversion - In this portion of the training, learners review what diversion is, how we monitor it at CHOP, and why it’s happening. Multimedia is used to review some examples of diversion and how to report errors and near misses.

• Case Scenario and Conclusion - Using an animated case scenario, this lesson provides a real scenario that occurred in the ED. The video pauses along the way, asking learners to make choices about what to do next. This application of knowledge evaluates whether learners have achieved the learning goals of the project. Finally, a summary of key ideas and resources is provided.

📊 Results:

The module was completed, reviewed, adjusted, and deployed within two weeks. As a result of implementing this program, safety incidents related to medication administration and the wasting of narcotics in the ED significantly reduced. The project was so successful that it was adopted and presented on an enterprise level as a review for clinical staff across multiple units.

📄 Conclusion:

While instructor-led training and on-the-job training and mentorship are excellent ways to address safety events, this asynchronous learning experience helped reduce medication administration errors, helping keep patients safe.