Design Changes Reduce Medication Errors at Sharp

Angie Mendoza, MS, BSN, RN-BC, CPHIMS, Sr. System Analyst, Liz Kozub, MS, RN, CCNS, CCRN, CNRN, Clinical Nurse Specialist – Surgical Intensive Care Unit, and Mary Swift, Pharmacy Analyst, Sharp HealthCare. Angie, Liz and Mary detail how a project team approach was used to address design changes to support safe medication administration. Our nurses identified several factors leading to medication administration errors, including improper use of Communication Orders, Clinical Display Line (CDL) configuration and a lack of consistent information. To address these issues, our project team focused on the following areas: clarifying order comments and adding hold parameters to anticoagulants and vasopressors, adding quick links for medication resources, revising epidural PowerPlans to provide clarity and mirror prompts in the Alaris pump, reconfiguring the CDL and implementing a Tylenol calculator to warn about cumulative dosing recommendations.