Implementation of a structured medication handover process: An evidence-based project


Long oral session 16: Evidence 2 Practice


Thursday 14 September 2017 - 16:00 to 17:30


All authors in correct order:

Ong IJ1, Bin Suid MA1, Lim AWZ1, Chong PLY1, Mettilda Rani A1, Tan M1
1 Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, Singapore
Presenting author and contact person

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Abstract text
Background: Medication errors may result in adverse patient outcomes. In 2015, there were 9 medication errors in a respiratory unit. This was attributed due to lack of communication between the nurses and variations in handover of medication at every shift.

Objectives: To reduce incidences of medication errors to 0, and to achieve 100% compliance rate of nurses practicing the structured handover of medication.

Methods: This project was commenced from January to December 2016. There were a total of four phases. Phase I involved analysis of medication incidences, retrieved from the best-available evidence to reduce medication errors from JBI COnNECT+ (Clinical Online Network of Evidence for Care and Therapeutics). The audit criteria were developed from the JBI Practical Application of Clinical Evidence System (JBI PACES). At phase II, JBI Getting Research into Practice (GRIP) module examined the barriers and identified interventions to improve the medication handover process. These included nurses receiving training sessions on how to use the acronyms 2DARTS for medication handover and utilisation of the pictorial guide. Phase III and IV involved post implementation and sustainment audits.

Results. The sustainment audit results has shown compliance compared to the pre-implementation and the sustenance phase. The handover of route of medication administration increased from 50% to 100%; Name, dosage and frequency of medication increased from 67% to 100%; Time of last-administered dose increased from 50% to 90%; Time of next dose increased from 50% to 90%; Used of sliding scale increased from 75% to 90%; and Documentation of omission reason increased from 74% to 75%. There was no reported incidence of medication error during the period from October to December 2016.

Conclusions: Medication errors has significantly improved due to nurses’ compliance in the structured medication handover process.