Using a Checklist as a Strategy to Reduce Errors During the Administration of High Alert Continuous Intravenous Medications

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Bryan College of Health Sciences
Purpose: The purpose of this quality improvement project was to create a medication safety checklist for high alert medications (HAMs) to be used by nurses during any patient handoff, and to evaluate its effectiveness. Will the implementation of a checklist, to be completed at all nurse to nurse handoffs, improve patient safety by decreasing the risk of HAM errors compared to not using a checklist or other double check processes? Literature Review: Reason’s Swiss cheese model of accident causation likens failures that occur on human and systematic levels to a stack of Swiss cheese slices. Research supports that when nurses do not utilize double check systems to their full potential, errors occur and negatively impact patients. Utilizing a medication safety checklist can aid in the reduction of errors by adding an additional layer of defense. Methods: After IRB review of the quality improvement (QI) project the stakeholders granted permission to begin the project. The stakeholders were managers of two ICUs in the Midwest. A checklist and survey were provided to bedside nurses. The checklist was utilized for HAMs at all nurse handoffs. Nurses also answered a short survey regarding their experience with the checklist. Completed forms were kept in a secure folder. Results: Three errors were identified by the checklist. Results showed that 81.5% of participants felt that the checklist helped improve patient safety. In total, 96.2% of participants felt that the checklist was easy to use. Some felt that the checklist added to their workload. We recommend stakeholders implement the checklist into the current workflow. Stakeholders received results via email along with a visual aid for them to use at their discretion. Conclusions: The utilization of a checklist as a double check is a valuable tool to help reduce or prevent patient harm and aids in positive patient outcomes.
High-alert continuous, Checklist, Medication, Patient safety
Gowan, C., Schwartz, L., & Buchholtz, A. (2020). Using a checklist as a strategy to reduce errors during the administration of high alert continuous intravenous medications [MSN Capstone presentation]. Lincoln, NE : Bryan College of Health Sciences.