Summary
An examination of how humans interact with their environments and each other led a team at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, USA, to question one of its long-standing medication safety practices and change how they work.
Content
Over the last five years, teams at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, had completed at least four different improvement projects focused on increasing adherence to the independent double check (IDC) process.
An IDC is when two registered nurses independently check a medication to ensure it is correct prior to administering it to the patient. Like other institutions, the hospital did not require this process for all medications but did require it for a select group of medications considered higher risk if given in incorrect doses, routes or times.
For years, the hospital examined and analyzed the process and related policies for administering these medications, but with no appreciable change in medication error rates. The latest efforts included reducing the number of medications that required an IDC, which pleased the nursing staff, but still did not fix the issue.
Then, in the summer of 2019, a medication administration error in the PICU triggered yet another root cause analysis of the IDC process.
The frustration of repeated analyses and efforts led the team to take a different approach to investigating its practices. They leveraged the expertise of a resident human factors practitioner—an expert in evaluating the interactions of people, tasks, the environment and technology—to lead the analysis.
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