Medication Error

Student Name:
EBP Journal Article in APA format:

Is this an Evidence Based Article? Name of Journal and Year article was written?

Name of Journal

.2 points

State the problem
What was the goal of the project in the article?
Does this project correlate with your problem? State how?
What are you trying to achieve? Does this article support this goal?

State how this article correlates with your group problem and goal.

.2 points

Strengths (Internal)
What’s was good about your article?

Why was this project successful?
List attributes of the article, i.e. support from administration, councils, colleagues, institutions.
Did this implementation take place on a unit or area like yours?

.4 points

Weakness (Internal)- issues

Example: lack of education, lack of staffing, staff readiness, lack of support; size, managerial style.

.4 points

Opportunities (External)

Example: Lack of supplies, educationalneeds, stakeholders, baseline (your baseline data), what needs to be improved?

.4 points

Threats – (External)

Staff buy in, support, limitations and barriers, supply cost, cost of implementation, time, money, realistic?

.4 points
Total Points = 2 points
Student Name: XXXXXXXX
EPB Journal Article in APA format:
Sánchez, M., Suárez, M., Asenjo, M., & Bragulat, E. (2018). Improvement of emergency department patient flow using lean thinking.International Journal For Quality In Health Care: Journal Of The International Society For Quality In Health Care,30(4), 250–256.

Is this an Evidence Based Article? Name of Journal and Year article was written?

Name of Journal: International Journal for Quality in Health Care
Year: 2018

.2 points

State the problem
What was the goal of the project?
Does this project correlate with your problem? State how?
What are you trying to achieve? Does this article support this goal?

Problem: Delays in the ED compromise quality of care and patient safety while simultaneously increasing mortality and healthcare costs. Internal inefficiencies and poor resource utilization may contribute to delays in care and overcrowding.
Goal: The goal of this project was to achieve a target time of 160 minutes (total), per patient in the ED.
· 80 minutes of “added value” (i.e. specific amount of time with a nurse and doctor for assessment, treatment, and education)
· 60 minutes for lab results
· 20 minutes for treatment steps that could not be eliminated using the Lean process
The goal of our group project is to propose a plan to decrease wait times and improve flow to care areas. The study outlined in this article directly correlates with our group project in that its aim was to tackle the issue of increased wait times leading to delay of care and negative outcomes, including decreased patient satisfaction and the increased risk for mortality. The goal of our group project is to propose a plan to reduce wait times in order to improve patient outcomes, which is exactly what the article’s researchers set out to do by proposing the use of lean principles to eliminate the unnecessary steps/processes that add to wait times.

.2 points

Strengths (Internal)
What’s was good about your article?

Staff Input: This project was heavily supported by the ED staff and administration. In fact, the ED staff were empowered to make the necessary changes by identifying steps (waste) that slowed flow and hindered the care process. They were also tasked with recognizing processes that could be standardized to improve efficiency in care.
Leadership Style: Furthermore, the researchers encouraged a “bottom-up” approach (democratic leadership) to achieve a more enthusiastic acceptance and implementation of the plan. The ED executive team acted as consultants to help support and foster the new process to reduce internal resistance.
Cost: The implementation of the entire project was inexpensive because it did not require third party support or additional supplies.
Did this implementation take place on a unit or area like yours: Yes, this project was implemented in an ED unit.

.4 points

Weakness (Internal)

Staff Support: According to the researchers, the most difficult problem they faced was staff reluctance to abandon their old practices and proceed with implementing the new process of standardization (which required 3 weeks of constant surveillance).
Size: This study was performed in a single ED unit that did not provide services to pediatric or obstetric patients, so it is unknown how well these results might carry over to other specialized ED units. Furthermore, to ensure proper control, the study was limited to a specific unit in the ED, MAT-3, which was the busiest unit in the ED and designated solely for urgent cases.

.4 points

Opportunities (External)

Patient Satisfaction: The results of this study showed that the ED staff was able to reduce wait times, overall care times, and improve patient flow using the lean process to eliminate wasteful steps. However, the researchers could have also measured patient satisfaction to determine if the lean process also improved the correlation between wait times and patient satisfaction.
Staff Satisfaction: The authors recognized that additional research should be completed to analyze how the lean process affects staff members in terms of work satisfaction, turnover, and improved use of skills.
Baseline Data: The researchers found no significant differences in the revisit rate, mortality rate, or leave without being seen rate (LWBS) after implementing the lean process. Suggestions for additional research meant to address these variables were not provided but should be explored, especially due to their relationship with patient safety.

.4 points

Threats – (External)

Validity: The researchers acknowledged that one of the greatest limitations of their study was its external validity since the study was performed in only one ED unit. Their methodology might not produce the same results in a more efficiently run ED unit.
Time: The researchers also agreed that the cultural change needed to fully adapt to this new standardized process would be an ongoing endeavor that would require additional time after the conclusion of the study. The researchers discounted the first 6 months of data because they anticipated that the staff would be more willing to embrace the new process, resulting in a false-positive outcome. Their aim was to observe how time also impacted the lean process in the ED unit in the following months.
Staff Buy In: Finally, the researchers also felt that the cultural/local interpretation of lean principles might differ depending upon location and/or unit. Previous studies concluded that the lean process did not provide clinically relevant results in ED units due to lack of staff buy in resulting from misinterpretation of lean principles. In other words, the staff must understand that the lean process is not a solution but a methodology.

.4 points
Total Points = 2 points
Improving medication appropriateness in nursing home residents by enhancing
interprofessional cooperation: A study protocol
Dagmar Schaffler-Schadena, Stefan Pitzerb, Magdalena Schreierb, Johanna Dellingerb, Beate Brandauer-Sticklerb,
Miriam Lainera, Maria Flamma, and Jürgen Osterbrinkb
aInstitute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria; bInstitute of Nursing
Science and Practice, Paracelsus Medical University, Salzburg, Austria
Polypharmacy in elderly people is an increasing challenge for health professionals. Drug-Drug interac-
tions, dosing or administration errors can cause preventable incidents and hospitalizations. Due to
chronic illness and multi-morbidity, older people are considered as a particularly vulnerable group of
patients. Furthermore, it is well known that communication between health professionals is often
insufficient. The aim of this study is to improve the appropriateness of medication of nursing home
residents by establishing a long-term structured medication review process and to enhance the inter-
professional communication between general practitioners (GPs), nurses and pharmacists. GPs review
and adapt medication of residents, nurses perform structured monitoring of residents for drug-related
symptoms. Pharmacists check the appropriateness of prescribed therapy by performing a medication
analysis. For this purpose, a special electronic platform (SiM-Pl) is developed to extend the original
health documentation system with additional tools. SiM-Pl enables participants to gain access to
relevant information regardless of time and place and shall facilitate health documentation and
exchange of information. All involved health professionals receive a topic-related, specific education.
The study is designed as a non-randomized, controlled trial. Health-related benefits and improved
quality of life are expected for the participating residents.
Received 7 July 2017
Revised 4 December 2017
Accepted 1 March 2018
communication; medication
review; nursing home
residents; polypharmacy
The incidence of chronic illnesses and multi-morbidity is
higher in elderly people and exposure to inappropriate med-
ication is common in this group of patients. Adverse drug
events can lead to pathologic conditions or even hospital
admissions, a challenge that the involved health professionals
are faced with daily (Patel, Patel, Patel, Naik, & Tripathi,
2017). The importance of good communication between
healthcare professionals for the clinical outcome of patients
is well known (Rice et al., 2010). Nevertheless, interprofes-
sional communication and cooperation are often insufficient,
with deficiencies in clinical documentation and exchange of
information leading to potentially harmful consequences in
patient care (Wilson, Palmer, Levett-Jones, Gilligan, &
Outram, 2016).
The SiMbA (Sicherheit der Medikamententherapie bei
Altenpflegeheimbewohnern – ‘safety of drug therapy in nur-
sing home residents’) study aims to improve appropriateness
of medication in nursing home residents by implementing a
long-term structured medication review process and intends
to enhance the interprofessional communication and coopera-
tion between general practitioners (GPs), pharmacists and
nurses to improve safety of drug therapy in nursing homes.
The study will have the following research questions: Is it
possible to improve the appropriateness of nursing home
residents` medication by complex intervention in the SiMbA
study? Can the SiMbA intervention encourage a change in
interprofessional communication and cooperation? Can the
SiMbA intervention furthermore help to alleviate symptoms
associated with drug therapy like delirium, restricted mobility,
and poor nutritional status?
Study type and study population
The study is designed as a non-randomized, controlled trial.
Nursing homes and hence their residents are non-randomly
assigned to the interventional or control group to minimize
the risk of contamination bias due to close structural and
personal relationships within and between potentially partici-
pating nursing homes (one common holding company).
The study will be conducted in nursing homes in Austria
for a duration of 2.5 years. The population includes general
practitioners and their patients in nursing homes, the nursing
staff of the participating nursing homes and the providing
CONTACT Dagmar Schaffler-Schaden Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus
Medical University, Strubergasse 21, 5020 Salzburg, Austria.
Color versions of one or more of the figures in the article can be found online at
Supplemental data for this article can be access on the publisher’s website.
2018, VOL. 34, NO. 2, 517–520
© 2018 Taylor & Francis
Recruitment and inclusion criteria
Recruitment of study participants includes several steps: GPs
who have a treatment contract with residents in participating
nursing homes are contacted primarily. They inform their
patients and invite them to participate in the SiMbA study.
Participation of nursing staff and providing pharmacists
depends on successfully recruiting at least one GP and his
or her patients per nursing home. All residents or their legal
representatives as well as all participating professionals have
to give informed consent.
Inclusion criteria for nursing home residents are, at least
65 years old, written informed consent of the resident or legal
representative, at least one prescription, no acute life-
threatening situation or isolation due to multidrug-resistant
infectious diseases. Inclusion criteria for health professionals:
GPs treating patients in nursing homes, pharmacists provid-
ing medication to nursing homes and nurses with at least 50%
part-time employment.
Data collection and outcomes
SiMbA utilizes quantitative face-to-face and self-administered
assessments as well as data from the nursing homes` docu-
mentary system about medical conditions of residents to
collect data for the following primary and secondary
● Primary outcome: Appropriateness of medication mea-
sured by the medication appropriateness index, (MAI)
(Hanlon & Schmader, 2013) . The MAI is an assessment
instrument to evaluate the appropriateness of a patients`
medication. The Mai score includes 10 items (e.g. indi-
cation for the drug, correct dosage of the drug, drug-
drug interactions, drug-disease interactions and other),
the summated MAI scores will be calculated by a clinical
pharmacist. For the calculation of the MAI the current
diagnoses and complete medication lists of the residents
are required.
● Secondary outcomes: Assessment of the residents’ mobi-
lity and tendency of falls, occurrence of delirium, the
registration of potential malnutrition and the evaluation
of health related quality of life (Table 1 – see online
supplementary file).
The improvement of cooperation and communication between
the participating health care professionals will be investigated
via qualitative individual interviews. The MAI scoring will be
carried out by independent clinical pharmacists.
Data collection will be performed at t0 (baseline data
collection), at t1 (after 12 months) and at t2 (after 18 months).
The collection and evaluation of the endpoint data sets at t0,
t1, and t2 will be conducted by trained study nurses and the
SiMbA project team.
The study intervention is semi-standardised and includes
three components. First, education for GPs, nurses, and
pharmacists focusing on pharmacotherapy in older adults,
drug risk management and related topics—combined as pro-
blem-based, interprofessional face-to-face and specific online
teaching suitable for each group, respectively. The training is
accredited and finishes with a multiple choice testing. The
training is divided into three parts, for those who are not able
to participate onsite, all lectures are video-recorded. The
training lectures are designed and conducted by a multipro-
fessional team consisting of two clinical pharmacists, one
nursing scientist and one specialist in internal medicine with
particular expertise in polypharmacy. The training starts with
an event with compulsory attendance for all professionals
together. This first meeting lasts about three hours and
includes the following topics: special characteristics of phar-
macotherapy in the elderly, pharmacokinetics and dynamics,
adverse drug reactions, medication errors, medication review
process and various legal aspects (e.g., mandatory reporting of
adverse drug events). The e-learning sessions are specially
designed for GPs, nurses, and pharmacists. For that purpose,
all participants gain access to the online learning platform of
the Paracelsus Medical University and are invited to complete
the online training before taking part in the third section of
the training. The training is completed after another onsite
session with all professional groups. This second meeting
focuses on the handling of the SiM-Pl online tool. A telephone
hotline will be available to study participants who have ques-
tions concerning the online platform, too.
Second, an online tool, the SiMbA-Platform (SiM-Pl), is
introduced to improve the structured exchange of information
and medication review between healthcare professionals. It is
the key tool for the interprofessional therapy check process.
The nursing staff of the participating homes within the SiMbA
study is already using a structured digital documentation sys-
tem. With the integration of SiM-Pl, the original documentary
system is extended by additional tools to avoid unnecessary
duplication. GPs and pharmacists can check and edit informa-
tion regardless of place and time using mobile devices.
Obligatory documentation for GPs and nurses shall be facili-
tated by SiM-Pl. GPs may access patient information via the
platform easily. Changes within medication may be transferred
to nursing staff immediately. Use of data is secured electroni-
cally and each professional gets an individual key access. The
platform meets current data protection regulations.
Third, medication of nursing home residents is checked by
a structured medication review process including the three
professional groups via SiM-Pl (Figure 1 – see online supple-
mentary file). After completion of the specific education pro-
gramme mentioned above, GPs check and if necessary adapt
the medication lists of their respective participating patients
within SiM-Pl. Medication lists are then released to the care
staff. As a next step within the process, pharmacists perform a
structured medication analysis type 1 (Bundesvereinigung
Deutscher Apothekerverbände, 2014). The medication analy-
sis type I may reveal drug-drug interactions, double prescrip-
tions, a potential inadequate time of administration or dosing
interval. The GPs may consider the pharmacists’ recommen-
dation regarding a medication modification and inform
nurses and residents. Feedback to the pharmacists from the
GPs whether the medication is changed after the analysis or
not seems useful. The information exchange is performed via
SiM-Pl and becomes immediately apparent in the documen-
tary system. Nurses perform a systematic observation of resi-
dents particularly with regard to possible side effects of the
drug therapy. For this purpose, the therapy monitoring form
(Thürmann & Jaehde, 2015) is adapted for the study. The
therapy monitoring form was developed by a German
research team to document notable symptoms possibly related
to a change of medication. The monitoring form is available
via SiM-Pl and includes items as mentioned below.
Monitoring of the residents after alteration or new prescrip-
tion of medication shall be performed daily during 5 days by
nurses and includes the following items: allergic reactions,
bleedings, gastrointestinal, cardiovascular and respiratory
symptoms, neurologic and psychiatric symptoms, as well.
Noticeable symptoms are documented and reported to the
GPs via SiM-Pl. As long as there is no change of medication,
regular monitoring will be performed by nurses once a week.
GPs and nurses can request medication analysis whenever
they see a need for it via SiM-Pl.
The therapy check process is divided into two phases: Within
the first 12 months, study participants will be accompanied by
the study team closely. In the second phase between t1 and t2,
study participants should be able to continue the medication
check process without the support of the project team.
Control group
The included residents in nursing homes receive usual care by
nurses, general practitioners, and pharmacists, respectively.
Hypothesis and required sample size
Based on existing evidence within literature and considering
the assessment inherent weighting of important items of
medication appropriateness, the minimal important difference
was defined for the primary outcome MAI as 3.0. We
hypothesize, that the interventional group will show at least
a −3.0 points better MAI- score compared to the control
group at t1 and, therefore, an increased appropriateness of
prescribed medication. We expect that the SiMbA interven-
tion positively influences known health-related outcomes
which had been associated with inappropriate medication
(risk of unintentional weight loss, delirium, health-related
quality of life and mobility).
Furthermore, interprofessional collaboration and commu-
nication between GPs, nurses, and pharmacists shall be
improved in the interventional group. All mentioned
improvements are expected to persist at the third data collec-
tion point (t2). The required sample size is calculated for
the minimal important difference of MAI as n = 29 per
group (α = 0.05; β = 0.20). Considering an expected dropout
rate of 37% (death of residents during the study period,
refusal to stay in the study), reaching n = 29 at t2 requires a
sample size of 46 per group at t0. Since refusal to participate is
assumed to be 75% in physicians and 50% in residents, n = 46
at t0 is reached, if the recruitment of GPs, which care for a
total of 369 nursing home residents, is attempted.
Ethical considerations
All study participants or their legal representatives have to give
informed consent. SiM-PL meets current legal data protection
requirements in Austria. The study was approved by the ethics
committee of lower Austria (GS4-EK-4/377–2016) and
Carinthia (MZ 24/16) and the SimbA study protocol was regis-
tered via DRKS (DRKS00012246)
Unplanned hospitalizations of elderly people can be related to
preventable adverse drug reactions (Albert, Colombi, &
Hanlon, 2010) and polypharmacy in elderly people can be
associated with impaired physical and mental health (Jyrkka,
Enlund, Lavikainen, Sulkava, & Hartikainen, 2011).
Improving relevant health outcomes and health-related qual-
ity of life of nursing home residents is, therefore, the main
goal of the interventions of the SiMbA study. Drug surveil-
lance and adaption of the most complex medication in multi-
morbid patients can be a challenging process for all healthcare
professionals involved (Ferrah, Lovell, & Ibrahim, 2017).
Errors may occur in several fields of the therapeutic treatment
chain – prescription, transcription, ordering, dispensing or
administration of medication. The SiMbA project will enable
the involved professionals to perform a structured surveillance
of the medication. Moreover, GPs can benefit from the com-
petent support of pharmacists and pharmacists have the
opportunity to bring in their expertise in the complex medical
treatment of multi-morbid patients, respectively. According to
our experience, the expertise of pharmacists is often not
included in a structured medication process (Costa, Van,
Abbott, & Krass, 2015). A recent German study has shown
that GPs would welcome the competent support of a pharma-
cist in the complex medical treatment of multi-morbid
patients (Loffler et al., 2017). Subsequently, the communica-
tion and cooperation of the involved health professionals
would be improved by using the SiM-Pl online tool.
Declaration of interest
The authors report no conflicts of interests. The authors alone are
responsible for the content and writing of this article.
This study is funded by Senecura Kliniken-und Heimebetriebs GmbH,
Albert, S. M., Colombi, A., & Hanlon, J. (2010). Potentially inappropriate
medications and risk of hospitalization in retirees: Analysis of a US
retiree health claims database. Drugs Aging, 27(5), 407–415.
Bundesvereinigung Deutscher Apothekerverbände. (2014). Überblick
über die verschiedenen Konzepte zur Medikationsanalyse und zum
Medikationsmanagement als apothekerliche Tätigkeit, Berlin: ABDA.
Costa, D., Van, C., Abbott, P., & Krass, I. (2015). Investigating general
practitioner engagement with pharmacists in Home Medicines
Review. Journal of Interprofessional Care, 29(5), 469–475. doi:10.3109/
Ferrah, N., Lovell, J. J., & Ibrahim, J. E. (2017). Systematic review of the
prevalence of medication errors resulting in hospitalization and death
of nursing home residents. Journal of the American Geriatrics Society,
65(2), 433–442. doi:10.1111/jgs.14683
Hanlon, J. T., & Schmader, K. E. (2013). The medication appropriateness
index at 20: Where it started, where it has been, and where it may be
going. Drugs Aging, 30(11), 893–900. doi:10.1007/s40266-013-0118-4
Jyrkka, J., Enlund, H., Lavikainen, P., Sulkava, R., & Hartikainen, S.
(2011). Association of polypharmacy with nutritional status, func-
tional ability and cognitive capacity over a three-year period in an
elderly population. Pharmacoepidemiology & Drug Safety, 20(5),
514–522. doi:10.1002/pds.2116
Loffler, C., Koudmani, C., Bohmer, F., Paschka, S. D., Hock, J.,
Drewelow, E., … Altiner, A. (2017). Perceptions of interprofessional
collaboration of general practitioners and community pharmacists – a
qualitative study. Bio Med Central Health Services Research, 17(1), 224.
Patel, N. S., Patel, T. K., Patel, P. B., Naik, V. N., & Tripathi, C. B. (2017).
Hospitalizations due to preventable adverse reactions-a systematic
review. European Journal of Clinical Pharmacology, 73(4), 385–398.
Rice, K., Zwarenstein, M., Conn, L. G., Kenaszchuk, C., Russell, A., & Reeves,
S. (2010). An intervention to improve interprofessional collaboration and
communications: A comparative qualitative study. Journal of
Interprofessional Care, 24(4), 350–361. doi:10.3109/13561820903550713
Thürmann, P., & Jaehde, U. (2015). Abschlussbericht zum Projekt
Arzneimitteltherapiesicherheit bei Patienten in Einrichtungen der
Langzeitpflege- eine prospektive Interventionsstudie. Retrieved from
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 perspec-
tives. Journal of Interprofessional Care, 30(5), 649–654. doi:10.1080/
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.
Study type and study population
Recruitment and inclusion criteria
Data collection and outcomes
Control group
Hypothesis and required sample size
Ethical considerations
Declaration of interest

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