Document Type

Dissertation

Degree

Doctor of Nursing Practice

Major

Nursing

Date of Defense

7-9-2021

Graduate Advisor

Alicia Hutchings, Ph.D., RN, CNE

Co-Advisor

Vanessa Loyd, DNP, Ph.D., RN

Committee

Emily Cooke, PharmD

Abstract

Abstract

Problem

Electronic medical records (EMR) have helped decrease common medication errors. However, prescribing errors are still elevated. Creating pre-built order sets can decrease medication errors for post-cesarean section women.

Methods

This project used an evidence-based practice approach to create new order sets. Women undergoing a cesarean section between January 15, 2021 and April 14, 2021 received the new order sets. A retrospective data review was conducted pre and post-implementation between the dates of October 15, 2021 and April 14, 2021 to view medication errors.

Results

Before implementation of the order sets, there were 239 cesarean deliveries and eight errors reported via Safety and Environmental Management Systems (SEMS) reports, and 45 errors reported via pharmacy intervention documentation reports. After implementation of the order sets, there were 281 cesarean deliveries. Reported errors via SEMS and pharmacy reports were decreased to 3 and 25 respectfully. Top medication errors reported via pharmacy reports pre-implementation were duplicate acetaminophen (n = 14, 29.79%) and overlapping ibuprofen and ketorolac (n=11, 23.40%) and post-implementation were duplicate ondansetron IV (n=11, 37.93%) and duplicate acetaminophen (n=8, 27.59%). According to SEMS reports, overlapping ibuprofen and ketorolac was the only error reported pre-implementation (n=8, 100%) and post-implementation errors included duplicate acetaminophen (n=1, 33.3%), overlapping ibuprofen and ketorolac (n=1, 33.3%), and duplicate oxycodone (n=1, 33.3%).

Implications for Practice

Order sets can provide pain control to post-cesarean section women. By decreasing medication errors, patients are kept safe from preventable mistakes. Using pre-built order sets can decrease provider error and thus medication errors.

Download

Share

COinS