Reducing Medication Errors by Systematically Monitoring High-Risk Medications

Date of Graduation

Summer 8-15-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Elena Capella

Second Advisor

Dr. T Gallo


Reducing Medication Errors by Systematically Monitoring High-Risk Medications

The project is performed in a pulmonary outpatient clinic, with a patient population of mostly men 60-80 years old with severe abnormal lung findings and often with multiple comorbidities. The clinic is staffed by pulmonary fellows in three-year rotations, providing two four hour clinics each week. They see 850 patients in a year, some of whom are seen every two, three or six months. The fellows schedules and workloads creates an issue for continuity of care and a need for medication and laboratory monitoring. This project will create a formal systematic approach to monitor high-risk medications (HRM) to ensure timely patient laboratory monitoring and prevent adverse drug reactions (ADR) that lead to hospital readmissions. The cost of one adverse drug reaction, leading to a hospital readmission, can vary from US$2200 to US$8300, depending on the severity of the reaction. In one study, the patients who were admitted for preventable ADRs were four percent of hospital readmissions, and of those readmissions, suboptimal monitoring occurred in 12 percent of the cases. The results of the intervention compared the patients taking HRM in February to the same patients in July, and of the 14 patients in the control group, six did not have current labs (42percent). A formal tracking system would highlight the gaps in care and act as a reminder to the CNL who is monitoring the patient that laboratory tests need to be ordered.

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