A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training.

Area of Science:

• Healthcare quality improvement
• Patient safety in pediatrics
• Nursing education and training

Background:

• Medication administration events (MAEs) are a significant concern in healthcare due to their frequency and cost.
• Pediatric patients present unique challenges to medication administration safety.
• The study aimed to enhance best practices, reduce MAEs, and lower associated costs through simulation training.

Purpose of the Study:

• To implement a scenario-based simulation training program for frontline nursing staff.
• To improve adherence to best practices in medication administration.
• To decrease the incidence and cost of medication administration errors in pediatric care.

Main Methods:

• A 2-hour simulation-based training program was developed, focusing on a Medication Administration Event (MAE) bundle.
• The MAE bundle included 'The Five Rights,' 'MedZone,' and 'Independent Double Check' protocols.
• Adherence was monitored through bedside audits for 18 months, using an institution-wide MAE reporting system.

Main Results:

• 1434 nurses participated in the simulation training across various units.
• Nursing adherence to the MAE bundle increased by 33% post-intervention.
• The medication error rate decreased from 2.5 to 0.86 events per month, yielding estimated annual savings of $165,000-$255,000.

Conclusions:

• Large-scale, target-specific simulation training effectively improved adherence to best practices.
• The training program led to a significant reduction in medication administration events.
• Simulation-based training offers a viable strategy for enhancing patient safety and reducing healthcare costs.