Competency in medication management is paramount in the acute care setting. This is no different in intensive care and cardiac care units given the large number of administered medications, including many that are designated as high-alert due to their potential for causing severe injury. Unfortunately, medication errors continue to impact inpatient safety despite the safeguards established among healthcare systems across the nation.

As three nursing professional development (NPD) specialists at one of the largest pediatric cardiac centers in North America, we sought to improve medication safety. Over the course of a year, we led an interprofessional initiative that improved medication competency through a carefully constructed plan and novel multimodal education approach. Competency was defined as maintenance of best practices in medication management, consistent with evidence-based guidelines, regulatory requirements, and internal policies and procedures. We share the details of our plan and approach in the hope that it may help others interested in employing similar methods.

Gathering Data and Evidence to Inform Our Plan and Approach

To achieve our goal, we first needed to fully understand our current state. We performed a comprehensive gap analysis that included a one-year review of medication safety incidents and results from the cause analyses, peer feedback from cardiac center experts and medication safety champions, and recommendations from hospital-wide medication safety team members who conducted a series of observations in our center. Four major themes were identified:

1. Inconsistent Labeling
   • Medications drawn up at the bedside
   • Large-volume medications and infusions
2. “Right” Medication
   • Inconsistent verification
     • Specifically high-risk medications requiring dual RN sign off
3. Critical situations with rapid medication prep and administration
   • Unclear interdisciplinary communication
   • Barcode scanning challenges
   • Automated dispensing system overrides
4. Large-volume medication administration via a secondary set-up
   • Incorrect set-up leading to medication errors

A review of the literature reinforced our findings that unclear communication and urgent situations precipitate errors. We also found several prevention strategies that were supported by the evidence, which included limiting interruptions during medication prep (Hermanspann et al., 2019), using a multidisciplinary staff education approach, and increasing staff awareness about the impact of medication errors in combination with the safety interventions to mitigate them. (Colligan & Bass, 2012)

Narrative citations: Adhikari et al. (2014), Colligan and Bass (2012), (Hermanspann et al. (2019), Wilson et al. (2016).

Developing and Implementing an Education Program

We created learning objectives directly linked to the themes identified through our gap analysis. Then we designed teaching strategies and evaluation methods for each objective. Our process was guided by evidence from the literature, and we incorporated regulatory requirements and organizational policies and procedures in our educational content. The use of an educational planning table helped to standardize the approach and ensure staff were given opportunities to learn content via multiple modalities. For organization, below is the table the team created.

Table 1. Education Planning Table

Objectives	Teaching Strategy/Content	Evaluation Type and Method
Apply the six rights of medication administration as outlined in the organization’s current policy and procedure	-Self-paced learning module	Knowledge: - Pre-test/post-test   Behavior: -Return demonstration
Demonstrate administration of a large-volume medication via secondary set up	-Self-paced learning module for background -Policy and procedure -Hands on demonstration and return demonstration -Case scenario in small groups	Knowledge: -Pre-test/post-test   Behavior: -Return demonstration
Demonstrate a two-RN verification	-Self-paced learning module -Policy and procedure -Case scenario exercise with return demonstration	Knowledge: -Pre-test/post-test   Behavior: -Return demonstration
Identify the components of a medication label when prepared by bedside clinician for administration	-Policy and procedure -Case scenario with return demonstration, group discussion	Behavior: -Reaction -Return demonstration
Demonstrate the process of drawing up, labeling, checking, and documenting a medication during an urgent situation (e.g., planned intubation)	-Policy and procedure -Case scenario with return demonstration and group discussion	Behavior: -Reaction -Return demonstration

 

Assessing staff needs for our large cardiac center became a critical factor in planning teaching strategies and content. For example, before we could offer hands-on demonstrations for a staff of more than 300 nurses, it was necessary to first provide background information through self-paced, asynchronous learning modules. A 15-minute refresher module that covered the main medication safety highlights for each learning objective was sufficient in restoring awareness for our experienced nurses. Three modules were chosen for their pertinent content from a library of previously developed modules.

Hands-on content was created by unit-based and hospital-wide experts and organized on a portable cart to deliver in-situ (on the unit, in the clinical environment vs. classroom setting) learning sessions throughout the center. The portable cart was equipped with all equipment needed such as IV pole with large volume infusion, laminated screenshots of the medication administration record (MAR) to assist with writing medication labels, and laminated policies and procedures for viewing to guide the education (e.g. two-clinician independent check). Facilitator guides were developed and kept on the cart to maintain fidelity and integrity of the educational content. Trainers were chosen based on experience and role.

For example, three of the trainers were organizational medication safety champions—taking an interest in medication safety practices, policies, and procedures. Additional trainers were recruited on a voluntary basis for bedside nurses with an eagerness to teach. Trainers were prepared by an in-person session and dry run utilizing the facilitator guide. A “train the trainer” method was used to foster peer-to-peer interaction and observation of return demonstrations, with a goal of providing psychological safety for the learner.

During implementation, we bolstered communication with staff via center-based social media, newsletters, and meetings. Strategic use of organization resources included electronic health record chats to inform staff of education opportunities each shift, protected trainer time through career development channels, and reinforcement of medication safety to new nurse residents. We also formally recognized the center’s safety efforts, such as staff trainers and nurses who contributed to medication, harm prevention, and good catches. For example, recognition took place on the organization’s intranet BRAVO site. These recognitions are public facing, include a brief synopsis of the scenario and a copy also gets sent to their manager for awareness and kudos.

Our multimodal education program would not have been possible without the support and collaboration of nursing leadership, the interprofessional medication safety team, evidence-based practice specialists, clinical nurse experts, safety-quality specialists, NPD specialists, and bedside nurses.

Evaluating Outcomes With an Evidence-Based Model

Nearly 90% of cardiac center nurses have completed the medication competency program to date.

We are evaluating the program using the Kirkpatrick Model, a well-established standard for assessing training methods through a combination of four levels that focus on the learner. An overview of some of our preliminary findings is provided below.

Level 1: Reaction—Learners find the training applicable, engaging, and relevant to their jobs

• Evaluated by anonymous online surveys, with Likert scale responses from 1 (unlikely) to 5 (very likely)
  • “Was this learning relevant to your job role?”—Mean score of 4.85/5.

Level 2: Learning—Learners acquire the intended knowledge, skills, attitude, and confidence following participation in the training

• Evaluated by a six-question test of content knowledge; pre- and post-tests were identical
  • Mean pretest percentage of correct responses: 64%
  • Mean post-test percentage of correct responses: 80%
• Self-reported confidence levels in performing skills were assessed using anonymous surveys, with Likert responses: 1 (not confident), 2 (somewhat confident), 3 (confident), 4 (very confident)
  • “How confident are you at applying the six rights of medication administration as highlighted in the organization’s procedures in your daily practice as a nurse?”—Mean score of 3.91/4.

Level 3: Behavior— Learners change their behaviors towards medication administration and safety

• Evaluated by anonymous online surveys, with Likert scale responses from 1 (unlikely) to 5 (very likely)
  • “How likely are you to apply this to your daily practice?”—Mean score of 4.62/5.
  • The aim of this result readiness to change

Level 4: Results—The degree to which targeted organizational outcomes occur because of the training initiative

• Current and future evaluations are being conducted to measure:
  • Large volume infusion labeling (weekly audits)
  • Data on barcode scanning and automated dispensing system overrides (biannual audits)

• • Further utilizing the data collected to calculate return on investment (ROI): as there is a potential for substantial cost savings related to medication waste.
    • For example, based on pre-program data, elimination of dispensing system overrides for just one commonly administered cardiac medication (e.g., calcium gluconate at $40/override) would yield a cost savings of $27,720.00 annually.
    • This is significantly greater than our estimated program costs for training during regular work hours, which is approximately $6,952.50 (average hourly nursing salary at $45 times 0.5 hours training times 309 nurses).

• • Reported medication error data at both the center and organizational level

Finally, a part of our evaluation involves a comprehensive review of program facilitators and barriers. Interestingly, through this process, we’ve found thus far that some anticipated barriers did not cause disruptions. Although staff worried that busy shifts would serve as a barrier to in-situ training, every participant completed the hands-on/return demonstration sessions within the program’s allocated timeline. Additionally, the evidence leaned heavily on the importance of interdisciplinary communication. As an adjunct to this work, the NPD team has begun to raise awareness to provider teams of the succinct communication needed during urgent situations. A small, interdisciplinary work group is coming together to address issues with communication and limit interruptions in urgent situations. This will hopefully alleviate stress, foster strong communication, and lead to safer patient outcomes with fewer medication errors.

Planning for Program Maintenance and Sustainability

As we are near a 100% program completion rate for cardiac center nurses and final data analyses of test and survey results, we now look toward next steps. Currently, we’re planning a quarterly maintenance of medication competency. We’ve also begun to engage in collaborations to expand medication competency training to additional intensive care and specialty units across our organization. We encourage NPD specialists to reach out to nursing and interprofessional colleagues in pursuit of similar programs. As advocates for education, competency management, and collaborative partnerships, NPD specialists are uniquely qualified to lead this important work.

References:

1. Adhikari, R., Tocher, J., Smith, P., Corcoran, J., & MacArthur, J. (2014). A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Nurse education today, 34(2), 185-190.
2. Hermanspann, T., van der Linden, E., Schoberer, M., Fitzner, C., Orlikowsky, T., Marx, G., & Eisert, A. (2019). Evaluation to improve the quality of medication preparation and administration in pediatric and adult intensive care units (Vol. 11). Drug, healthcare and patient safety, 11-18.
3. Irajpour, A., Farzi, S., Saghaei, M., & Ravaghi, H. (2019). Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. Journal of education and health promotion, 8(1), 196.
4. Colligan, L., & Bass, E. J. (2012). Interruption handling strategies during paediatric medication administration. BMJ Quality & Safety, 21(11), 912-917.
5. Wilson, A. J., Palmer, L., Levett-Jones, T., Gilligan, C., & Outram, S. (2016). Interprofessional collaborative practice for medication safety: Nursing, pharmacy, and medical graduates’ experiences and perspectives. Journal of interprofessional care, 30(5), 649-654.

6. Sears, K., O'Brien-Pallas, L., Stevens, B., & Murphy, G. T. (2016). The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors. Journal of pediatric nursing, 31(4), e283-e290.
7. Smidt, A., Balandin, S., Sigafoos, J., & Reed, V. A. (2009). The Kirkpatrick model: A useful tool for evaluating training outcomes. Journal of Intellectual & Developmental Disability, 34(3), 266–274. https://doi.org/10.1080/13668250903093125
8. Children's Hospital of Philadelphia. (2024). Checking A Medication Before Administration: Procedure. Privacy and confidentiality policy. PolicyMedical. https://chop.policymedical.net/policymed/anonymous/docViewer?stoken=14de2fa8-d9f5-4188-983b-29545b20809f&dtoken=d483aa55-d25a-4401-9b90-4453a626eaa0