Forum Fosters Bright Ideas

An estimated 1 in 30 patients are exposed to preventable medication errors worldwide, according to a meta-analysis in the peer-reviewed journal BMC Medicine. Drug-related mistakes, which are among the most common causes of patient harm, can arise when an incorrect dose or drug is administered, an incorrect delivery method is used or a medication is given to the wrong patient or to the right patient but at the wrong time.

This past spring, The Stanley Shalom Zielony Nursing Institute for Nursing Excellence hosted an interdisciplinary ideation session to solve the problem by generating a variety of ideas.

“Our goal was to receive a large quantity of ideas from multiple stakeholders to prevent medication errors in the inpatient setting, as medication errors can jeopardize patient safety and lead to complications,” says Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN, Executive Director and Associate Chief Nursing Officer for Nursing Research and Innovation.

Protecting both patients and caregivers

The Zielony Nursing Institute has previously held ideation sessions to generate solutions for other issues, including nurse/patient communication systems and patient falls. The decision to tackle medication administration errors stemmed from an executive nursing leadership team meeting. During a robust discussion among chief nursing officers and associate chief nursing officers about quality and safety issues, Albert suggested using an ideation session to develop solutions that reduce the risk of preventable medication errors.

“Medication administration is a core function of hospital-based clinical nurses — and, unfortunately, medication errors have plagued the global nursing profession for a long time,” says Maureen A. Schaupp, MSN, APRN-CNP, Executive Director and Associate Chief Nursing Officer of Advanced Practice Nursing and Nursing Quality and Practice. “We wanted to gather nurses who administer medications, pharmacists who prepare medications and other stakeholders to come up with ideas on how we can make the processes of medication preparation and delivery safer for our patients. How can we help our nurses do the right thing, most easily and reliably, over and over again to produce quality results?”

Medication errors are a pervasive problem across hospital sites and settings that can not only lead to patient harm but also traumatize nurses. “When nurses discover that they are the individual who created a medication error, they may react by becoming stressed, anxious, and worried for their patient. In addition to emotional reactions, they may develop physical symptoms of stress,” says Albert. “No one wants to create patient harm or even worry that there could be patient harm. After medication error events occur, nurses may change the way they deliver care, as a lesson learned, but our goal is to prevent errors from occurring!”

Medications that are liquid and come in ampules or vials often look alike (ampule/vial size, label coloring, cap coloring, etc.) and are of great concern, but even oral tablets can be mistaken for another drug, especially when many medications are delivered at the same time. Albert notes that pharmaceutical companies have not individualized medications to assist in error prevention.

Session leads to solutions and prototypes

Nursing leaders invited 16 clinical nurses from Main Campus and regional hospitals throughout the enterprise to the four-hour ideation session that was co-led by Albert; Karen Schaedlich, MSN, RN, Innovation Program Coordinator in the Office of Nursing Research and Innovation; and Cleveland Clinic Innovations team members, who foster healthcare innovation and technology transfer. Other attendees included two clinical nurse specialists, two pharmacists and two engineers.

“We wanted interdisciplinary representation and experts in clinical specialties where medication administration errors are most likely to occur, such as critical care and diabetes care,” says Albert.

When kicking off the ideation session, Schaupp discussed the problem (nationally and locally) and posed a question: How might we eliminate medication errors in the inpatient setting? Participants were then given time to ponder the question and record their ideas on sticky notes.

Next, Schaedlich led a visual stimulus activity. She showed the group four pictures that were totally unrelated to nursing, including a colorful playground and a restaurant kitchen. “We wanted to tap into the unique connectivity that these pictures might spawn,” says Schaedlich. “That’s one of the ways to get fresh ideas that enable us to take a deeper dive into the creative aspect of innovation.”

Within 40 minutes, the group had generated more than 220 ideas ranging from process enhancements to new devices. The sticky notes were displayed on a whiteboard, and participants placed stickers next to their favorite ideas. Albert and Schaupp grouped similar concepts into several themes and then selected the top four themes for further ideation.

Attendees were divided into four small groups for a 45-minute hands-on breakout ideation session focused on one of the top themes that had been identified. The groups used construction paper, molding clay, pipe cleaners, scissors, glue, rulers and other supplies to create simple prototypes. For processes, participants used poster paper and markers to describe their prototypes or novel solutions.

The final segment of the ideation session involved solution sharing. All members reconvened to share their solutions, answer questions and elicit ideas from the audience.

“The activity really brought solutions to life,” says Schaedlich. “Although the prototypes were very early in development, it was easy to understand the vision and what each group was trying to accomplish.”

Three participant groups came up with devices, and one group proposed an internal innovation. Since the ideation session, the groups have held follow-up meetings to further develop and refine their solution prototypes. All four groups completed invention disclosure forms, and two of the groups are planning research studies to determine the value of their inventions.

“The next step is to create research proposals, secure institutional review board approval and study the planned research outcomes when the intervention is used in day-to-day practice,” Albert says.

Tool of empowerment

Schaupp was energized by the ideation session and says she is excited to watch the medication administration solutions continue to develop. “When you get people together with common goals, amazing things can happen,” she says. “It’s great to work with nurses who are empowered to solve problems by being given the tools and the time they need to focus on generating ideas.”

Schaedlich plans to lead more ideation sessions in the future and encourages nursing professionals in other health systems to explore a similar approach. “It’s not a one-time exercise, and it doesn’t have to be enterprise wide,” she says. “You can hold ideation sessions in one hospital, one department or one nursing unit.”

“When a commercial solution is unavailable, ideation sessions can be a vital tool for addressing long-standing problems and finding novel solutions,” Albert says.

“Innovation is a tool that can be used to promote change and growth, show support for staff and improve nursing care and practice,” she says. “Medicine constantly changes; nursing needs to change as well. And innovation is part of that change.”