Implementing best practice in medication management in a nursing home

Medication management is one of the major roles of a nurse leader in any health care setting particularly in the nursing homes. Evidence suggests that errors do occur at any stage of the medication use process (prescribing, documenting/transcribing, dispensing, administering and monitoring) and these might pose significant risks to older people in nursing homes. Thus, this change project was carried out to reduce the incidence of medication errors, ensure resident’s safety and promote compliance with professional and national standards on medication management. A multiple approach using the PDSA cycle and Kotter’s eight steps change model was adopted to guide the change project. Data were collected 4 weeks prior to the implementation of this change project and the following types and frequency of error were detected : error detected through chart review include transcription error (2), omission error (4) and wrong time error (2); error detected through observation include wrong form (crushing medication-4), wrong time (1), wrong patient (2) and wrong dose (5) while medication incident reporting form detected omission error (1) and wrong dose error (1). At the end of 5 months, data were collected through chart review, medication error reporting form and observation. Results showed that there was reduction in errors associated with lack of nurses’ knowledge on medication given resulting in brand name versus generic name confusion leading to transcription error . Wrong dose , wrong time, omission, wrong resident and wrong form errors were also observed to be significantly reduced.