Abstract

"To Err is Human," a report set forth by the Institute of Medicine (IOM), significantly underestimated the magnitude of medication error impact on patient morbidity and mortality (IOM, 2001; IOM, 2015). To improve healthcare quality, IOM established five competencies to improve the quality of healthcare delivery: relationship-based care (RBC), evidence-based practice (EBP), quality improvement, interdisciplinary teams (IDT), and use of informatics. According to The Joint Commission (2015), communication errors are identified among top three root causes of sentinel events. The synchronized approach of utilizing core competencies translates into quality patient-centered care through effective communication and therapeutic relationship between patients and healthcare providers. For this Quality Improvement Project, a designated pharmacist was utilized as an active participant in interdisciplinary treatment teams where patient and staff communication occurred as an open dialogue. The pharmacist was responsible for medication orders, checking for medication interactions, medication reconciliation, and any education pertinent to medications. SBAR was utilized to improve the effectiveness of communication among team members and T-TAQ survey was offered to all nursing staff to assess their perception on teamwork and communication before and after project implementation. Medication errors were monitored by the inpatient pharmacy using an internal, dual-password protected system.

Author Details

Victoria Kozel, DNP, FNP/PMHNP

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Quality Improvement

Research Approach

Quantitative Research

Keywords:

Interdisciplinary Treatment Team, Communication, Reducing Medication Errors, Medication Errors, Pharmacist, SBAR, Effective Communication, Situation-Background-Assessment-Recommendation

Advisor

Unknown

Degree

DNP

Degree Grantor

Jacksonville University

Degree Year

2020

Rights Holder

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All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

Faculty Approved: Degree-based Submission

Acquisition

Self-submission

Date of Issue

2020-05-06

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