Reducing medication administration errors at a local mental health unit

Sizwile Tshuma Clinical Nurse Consultant Mental Health Service, Shellharbour Hospital, Illawarra Shoalhaven Local Health District, New South Wales

Background

Research has indicated that medication errors contribute to unintended harm to consumers of health services.

Problem/Aim

The mental health unit in this study has the highest rate of medication administration errors within the local health district. The aim of this quality improvement project was to reduce medication administration errors in the mental health unit by 50% within 6months.

Design

The project used clinical practice improvement methodology to engage staff and consumers in process mapping the medication administration process from the nurse to the point of care. Both consumers and nursing staff identified several ideas to reduce medication administration errors and to improve the experience for the consumer. The project tested several ideas in multiple Plan-Do-Study-Act (PDSA) cycles within the mental health unit. Improvement ideas were either implemented, modified or left for a later date on the basis of cost, run chart data, mental health unit consumers and team feedback.

Results

Ideas that were successfully implemented include: • individual folders for medication charts

• redesign of medication room (e.g., swipe access for security, decluttering, ventilation and glass panel in door for visibility/safety) • medication administration education

• night-station medication room closure

• weekly auditing of drug register • one-on-one coaching • feedback from consumers at the

Weekly Consumer Meeting. Run charts demonstrate a reduction in reported and unreported medication administration errors as a result of these interventions.

The huge reductions in reported and unreported incidents in September and October 2017 were due to daily auditing of drug registers, delivery of staff education, one-on-one coaching and implementation of individual medication chart folders.

Next steps

Sustainability of these improvements is yet to be established over the next few months. Further PDSA cycles will continue as the outcomes of the project become embedded in practice. Hopefully, long-term gains will improve consumer experience and adherence to their medication, and dissemination will be achieved by sharing lessons learnt with other mental health units.