Author: Judy Young, RN, MS
Institution: Indiana University School of Nursing
Coauthors: Elizabeth Burgess, BSN Indiana University School of Nursing Pam Ironside, PhD, RN, FAAN Associate Professor Indiana University School of Nursing
Identify system barriers and facilitators of effective team functioning.
Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals.
Demonstrate effective use of strategies to reduce risk of harm to self and others.
Communicate observations or concerns related to hazards and errors to patients, families and the health care team.
Examine human factors and other basic safety design principles as well as commonly used unsafe practices.
Participate appropriately in analyzing errors and designing system improvements.
Value vigilance and monitoring by patients, families, and other members of the health care team.
Facilitate systems thinking, patient safety within a complex adaptive system, through education and client/family collaboration.
Foster collaborative partnerships between academic and service settings.
The goal of the strategy is to immerse students in a quality improvement group project focused on medication reconciliation and patient safety. This exercise spans 2 weeks during which students practice medication reconciliation in the classroom and clinical practice settings.
Week 1: Extracting a Medication List (see PowerPoint presentation) Students work through the steps of medication reconciliation in class, role playing interactions and thinking together about potential risks and ways nurses can intervene in such encounters. Faculty guide students to consider:
How to obtain a complete/thorough medication list and history
How to identify possible medication interactions and the relationships among medications and abnormal physical findings
How to identify gaps in knowledge – specifically identifying how to ask focused questions and probe for additional information (i.e. exploring herbal and/or natural supplements in addition to prescribed medication) to assure care givers have a clear understanding of what medications patients are taking and how they are taking them.
How to identify real or potential systems failures – specifically identifying a) systems that are influencing (or have the potential to influence) medication adherence (or lack thereof), b) communication breakdowns that are influencing (or have the potential to influence) medication adherence, c) the extent to which the patient record contains an accurate picture of the patient’s medication history and adherence
The specific actions nurses can take to promote patient safety and quality care through medication reconciliation.
Week 2 : Moving into the clinical setting Students apply what they have learned in the clinical setting by completing medication reconciliation activities on an assigned patient. Faculty use post-clinical conference to explore identified safety issues and how these can be rectified. Concomitantly, students engage in a group project to extend their knowledge related to mediation reconciliation and to promote safety in the clinical area where they are completing their practicum. Specifically, students are asked to:
Complete literature review relating to medication reconciliation and safety
Draft/revise a policy/procedure for medication reconciliation specific to their assigned unit
Complete patient record audits to document healthcare team compliance
Provide education to staff/physicians/patients relating to the medication reconciliation policy and procedure.
Note: Many quality and safety topics can be woven into discussion. It is helpful for faculty to direct students’ attention to patient safety initiatives to contextualize the exercise. Also, by consistently using quality/safety terminology in discussions (e.g.: medication reconciliation, complex adaptive systems, transparency, collaboration and so forth) students become familiar with and adept at considering both individual and system perspectives.
This is an ungraded experience. In the syllabus, this experience is described as follows:
This exercise is not graded but it shapes the entire practicum experience which is designed to focus on safety and quality improvement. Throughout this semester, you will be guided to appreciate and apply quality improvement concepts while contributing to safety and quality improvement in your assigned clinical setting.
Both qualitative and quantitative data can be used to assess students’ participation in and perceptions of this educational experience. Qualitative questions to which students have responded include:
What did you learn from this experience?
What do you know now that you didn’t know before?
What did this experience mean to you as a student nurse?
Quantitative data have been collected by asking the students complete a summative evaluation tool. This tool has one question for each of the objectives and asks students to respond by indicating the extent to which they believe this exercise contributed to their meeting each objective (using a scale ranging from 1-5 –strongly disagree to strongly agree).
Outcomes of this experience include 1) student enthusiasm (students really began to see what a difference quality improvement makes and were eager to become involved in other QI activities), 2) student empowerment (students took ownership of creating new evidence-based policies/ procedures, patient educational documents, marketing strategies (buttons) sharing them with nurses, physicians and other healthcare providers. Currently 28 clinics associated with this system are considering the implementation of the students’ policy and procedure for medication reconciliation), 3) teamwork/collaboration (students experienced being a real part of the team and earned the respect of other nurses, physicians and other healthcare professionals, several of whom sought out students for clarification regarding their role in medication reconciliation) and 4) students engagement (students relished involvement in activities that “made a difference” on clinical units and were eager to extend and expand these activities).