Presentation
Workflow Disruptions and Adaptive Nursing Strategies in Pediatric Intensive Care Medication Administration
SessionPoster Session 1
DescriptionIntroduction: Medication administration is one of the most frequent and safety-critical nursing tasks. Over the past two decades, the nursing work related to medication administration has evolved with the introduction and use of electronic health records, “smart” infusion pumps, medication bar-coding, and the introduction of controlled access medication cabinets. However, these changes have not been associated with significant improvements in medication safety (Mulac, 2021; Giuliano, 2018). The limited progress in meaningfully improving medication administration safety suggests that the process itself may not be well understood. Nursing work has been observed to be full of problems (when something needed for care is missing or in the way of care delivery).Tucker and Edmonson distinguish between first-order problem solving, in which the immediate problem is resolved, and second-order problem solving, in which the nurse addresses both the problem at hand and its underlying cause. (Tucker, 2003). The nursing work of medication administration, the routine challenges and problems encountered, and the associated adaptive strategies nurses use to problem-solve represent critical yet under explored aspects of medication administration.
Prior research has identified workflow disruptions (Dasgupta, 2011; Pirinen, 2015; Garrett, 2009), their potential to compromise patient care and safety (Alteren, 2018; Huynh, 2016) and has examined nursing problem-solving in adult care settings (Tucker, 2002; Eisenhauer, 2007)). However, little is known about the specific problems Pediatric Intensive Care Unit (PICU) nurses encounter during medication administration, and how they address these problems in real-time (Holden, 2013). Pediatric medication administration carries unique risks due to weight- and age-based dosing, physiological differences, and frequent off-label use. To address this gap, a prospective observational study of scheduled medication administration by nurses in a PICU was conducted. This study aimed to characterize the problems encountered during medication administration across three phases of medication administration: 1) pre-care 2) medication preparation, and 3) administration of medication. Additionally, the study aimed to describe the observed adaptive strategies nurses used to overcome these disruptions; and to explore how these adaptations may introduce safety hazards.
Methods: This prospective observational study focused on administration of scheduled medications by bedside nurses in a 44-bed academic PICU at a free-standing children’s hospital. The project was determined to be non-human research by the institutional review board, and no identifiable provider or patient information was collected. Trained observers (AB and AC) collected data and refined methods with input from human factors engineering (HFE) professionals and nursing experts. Those problems observed during medication administration and categorized them into one of three phases: pre-care, medication preparation, or administration of medication. Observed problem solving strategies were associated with the underlying problems.
Results/discussion: Over 50 hours of direct observation revealed multiple problems across all three phases of medication administration. Additionally, multiple examples of first-order problem solving were observed in response to these problems. We did not witness any examples of second-order problem solving.
In the pre-care phase, problems included medication inventory issues, inaccurate electronic health record (EHR) orders, and system inefficiencies caused delays. For example, when a medication was out of stock [problem], nurses had to search other physical locations within the PICU [problem-solving], leaving their patients temporarily covered by another nurse – and thereby increasing their patient load [hazard]. In medication preparation, barcode scanning failures, pump programming difficulties, and missing supplies created inefficiencies. For example, if no pill crusher was available [problem], nurses improvised with inadequate tool [problem-solving], resulting in incompletely dissolved medication [hazard]. During the administration of medication, clogged enteral tubing, duplicate orders, and medication incompatibility disrupted workflow. For example, when two IV medications due at the same time required separate infusions [problem], nurses had to decide which to give first [problem-solving], causing the second to be delayed [hazard]. Interruptions from providers, pharmacy staff, other nurses, maintenance personnel, and families were frequent and spanned all medication administration phases. Each of these system issues represented hazards that have the potential to harm patients.
Conclusion/next steps: We repeatedly observed nurses employ first-order problems solving in response to problems encountered during medication administration. While these strategies are essential for delivering safe patient care, they may obscure underlying system issues which may represent safety hazards. Further exploration of second-order problem solving by nurses may add to the safety of medication administration as well as reduce recurrent problems. Additionally, future work could aim to quantify the impact of these medication administration disruptions to inform interventions that improve safety in pediatric medication administration.
Prior research has identified workflow disruptions (Dasgupta, 2011; Pirinen, 2015; Garrett, 2009), their potential to compromise patient care and safety (Alteren, 2018; Huynh, 2016) and has examined nursing problem-solving in adult care settings (Tucker, 2002; Eisenhauer, 2007)). However, little is known about the specific problems Pediatric Intensive Care Unit (PICU) nurses encounter during medication administration, and how they address these problems in real-time (Holden, 2013). Pediatric medication administration carries unique risks due to weight- and age-based dosing, physiological differences, and frequent off-label use. To address this gap, a prospective observational study of scheduled medication administration by nurses in a PICU was conducted. This study aimed to characterize the problems encountered during medication administration across three phases of medication administration: 1) pre-care 2) medication preparation, and 3) administration of medication. Additionally, the study aimed to describe the observed adaptive strategies nurses used to overcome these disruptions; and to explore how these adaptations may introduce safety hazards.
Methods: This prospective observational study focused on administration of scheduled medications by bedside nurses in a 44-bed academic PICU at a free-standing children’s hospital. The project was determined to be non-human research by the institutional review board, and no identifiable provider or patient information was collected. Trained observers (AB and AC) collected data and refined methods with input from human factors engineering (HFE) professionals and nursing experts. Those problems observed during medication administration and categorized them into one of three phases: pre-care, medication preparation, or administration of medication. Observed problem solving strategies were associated with the underlying problems.
Results/discussion: Over 50 hours of direct observation revealed multiple problems across all three phases of medication administration. Additionally, multiple examples of first-order problem solving were observed in response to these problems. We did not witness any examples of second-order problem solving.
In the pre-care phase, problems included medication inventory issues, inaccurate electronic health record (EHR) orders, and system inefficiencies caused delays. For example, when a medication was out of stock [problem], nurses had to search other physical locations within the PICU [problem-solving], leaving their patients temporarily covered by another nurse – and thereby increasing their patient load [hazard]. In medication preparation, barcode scanning failures, pump programming difficulties, and missing supplies created inefficiencies. For example, if no pill crusher was available [problem], nurses improvised with inadequate tool [problem-solving], resulting in incompletely dissolved medication [hazard]. During the administration of medication, clogged enteral tubing, duplicate orders, and medication incompatibility disrupted workflow. For example, when two IV medications due at the same time required separate infusions [problem], nurses had to decide which to give first [problem-solving], causing the second to be delayed [hazard]. Interruptions from providers, pharmacy staff, other nurses, maintenance personnel, and families were frequent and spanned all medication administration phases. Each of these system issues represented hazards that have the potential to harm patients.
Conclusion/next steps: We repeatedly observed nurses employ first-order problems solving in response to problems encountered during medication administration. While these strategies are essential for delivering safe patient care, they may obscure underlying system issues which may represent safety hazards. Further exploration of second-order problem solving by nurses may add to the safety of medication administration as well as reduce recurrent problems. Additionally, future work could aim to quantify the impact of these medication administration disruptions to inform interventions that improve safety in pediatric medication administration.
Authors
Event Type
Poster Presentation
TimeMonday, March 234:45pm - 6:15pm EDT
LocationRhinelander Gallery
Patient Safety Research and Initiatives