Safe Medication Practices

Sample Lesson Plan

Developed by

NurseLearn – A Division of Diversified Healthcare Consulting

PO Box 844

Mustang, OK 73064

Lesson Plan

Subject: Reducing Medication Errors Through Safe Practices

Suggested class length: 60 min.

Topic

Outline

Teaching Methods/Aids

Time

Comments

Introduction

Welcome participants, explain class focus and introduce participants to one another.

Recommend icebreaker activity for introductions unless participants are all very familiar with one another.

5 min.

More time may be needed for an icebreaker activity. Suggest Blackout Bingo – see handout

Medication Errors

1. Working definition

2. 5 phases of med use systems

Instructor slides, flip chart or board for writing participant comments.

Elicit participants’ definitions of a medication error first and write on board/chart.

5 min.

Present basic working definition of a medication error with particular focus on your agency policy/definition.

Why Errors Occur

3. System Failure – latent and active

4. Human Factors Engineering

	Perception/reality
	Distractions
	The unexpected

5. Most common types of errors

Instructor slides, handouts (if desired) of examples of both active and latent system failure experienced in your own system.

Explore what has been learned from human factors engineering about the role of perception/reality, distractions and dealing with the unexpected in causing med errors.

10 min.

· Discuss the ‘person approach ‘ vs. the ‘system approach’ for examining medication errors.

· Explore reasons why the ‘person approach’ seldom leads to prevention of future similar errors.

· Give examples of active vs latent system failures.

7 “rights” of Medication Administration	Patient – Medication – Dose – Route/technique – Frequency/time – Form - Documentation	Instructor slides; class discussion of any additional recommendations they have.	10 min.	Present recommendations to reduce errors for each of the seven ‘rights’.
Safe Practices	Short term Intermediate Long-term	Instructor slides ; Recommended learning game – Envelopes (see attached) Present practice recommendations that every nurse can do immediately- then focus on what actions may take group effort among units/department. Focus last on major changes that nursing can advocate in changing unsafe systems (things that usually cost money, etc.)	20 min	Focus on current dangers known such as: · Legibility · Look alike-Sound alike drug names · Alphabetical storing of drugs · Verbal orders · Unsafe abbreviations · Facsimile ‘noise’ · Lined order sheets · Similar patient names/patient ID problems · Similar manufacturer labeling · ,etc.
Handling Narcotics	Controlled drugs, Federal and State Laws, Licensed Nurse Responsibilities	Instructor slides	5 min.	Review requirements and systems required within your own facility for storage and accountability.
Evaluation	Conduct formal and/or informal evaluation of class; use post-test if desired.

Blackout Bingo

Icebreaker

Class Size: from 5 to 35+

Materials Needed: Blank Paper

Time required: About 10 to 15 minutes (depending on size of group); or can be time-limited by the facilitator.

Instructions:

Blackout Bingo: Give each learner a blank piece of 8 ½ by 11” paper. Instruct them to fold the paper in half, and then fold it again two more times. When the paper is unfolded there will be eight blocks on the paper. Instruct participants to write their answers to eight introductory questions in each block. You might put these questions on a flip chart or an overhead. Questions might include some of the following (or make up your own):

a. What is the first letter of your last name?

b. What is your favorite color?

c. How long have you been (a nurse, an employee, a manager, etc.)?

d. State one thing you hope to learn in this class today?

e. State one thing about this topic you already know?

f. What is your favorite hobby?

g. What do you like most about (working here, attending workshops, etc.)?

h. How far did you have to travel to get here today?

After each participant has filled in his/her paper instruct the group to find someone else in the group who has the same answer. The person with the same answer must sign his/her name in the block (only one block to a person). The first person to get all his/her blocks signed calls out “BINGO”. Or you may call an end to the exercise after a few minutes. At the end of the exercise ask each participant to introduce at least one person who signed his or her paper.

Envelopes – A Learning Reinforcement Activity

Recommended Class Size: Suitable up to about 30

Materials Needed: Envelopes and index cards

Time Required:

Instructions: Create a set of envelopes, writing on the front of each envelope one “safe medication practice’ issue to be discussed, such as the following:

· handling same or similar sounding drug names

· providing safer storage

· dealing with legibility issues

· problems with patient identification

· administration of unfamiliar drugs

· handling verbal orders

· safer practices any nurse can do immediately (no money, no policy changes needed)

· safer practices that the organization should initiate (bigger projects)

Feel free to make up your own list of issues to be discussed regarding safe mediation use practices pertinent to your organization. Each envelop should have a different topic.

Organize participants into groups if the class has more than six participants. Group size should be at least 3 but not more than 6 members each. With fewer than six participants, play ENVELOPES as a contest among individual players.

Arrange the team tables in a roughly circular configuration. Explain that during the game, each team will pass an envelope to the next team in a clockwise direction.

Give one envelope and several index cards to each team. Ask the members of each team to review the topic on the envelope, think of a list of several responses to the topic and put these on an index card.

TIME LIMIT: Allow each group a set time to brainstorm responses, such as 3 minutes. The groups must then place their index card with the responses inside the envelope, leave the envelope unsealed and pass it to the next group. Emphasize that the teams should NOT open the envelope they receive.

Repeat the procedure until each group has responded to the topic on each envelope. At the end of the activity ask each team to open the envelope they have, pull out all the response cars and decide which responses they found the best. Give a time limit for this activity (e.g. 5 or 7 minutes).

Ask each team to announce the results of their evaluation activity giving the best safety practices to address the medication safety issue presented on the envelope.