Emergency Department Nursing Medication Administration Documentation

Purpose:
The absence of standardized medication administration documentation by Emergency Department nurses causes creation of shortcuts, incomplete documentations, and non-compliance. The goal is to have 100% of medication documentation administration by ED nurses using the electronic medication template.

Significance:
The lack of standardized process for documentation of medications administered by ED nurses can present significant threat to patient safety. Healthcare team relies on the accuracy of the medical record, but if the information does not reflect this, potential serious adverse events can happen.

Strategy and Implementation:
A team was formed to correct the issue identified through the use of Lean concept. The team was divided into several groups at different times to study current processes of medication administration and documentation by process mapping, direct observation using a spaghetti diagram and chart reviews. Weekly team meetings were scheduled to discuss findings and strategies. With the review of the current processes, several non value added practices were identified. The team created a future state process to eliminate operational barriers. The Nursing Assessment note was revised to include the new electronic medication administration template for all medications including respiratory treatments. Staff education was conducted on the use of the template. Daily chart reviews were conducted until 100 % compliance is achieved with minor adjustments to the template as needed. Random monitoring is continued and reported to nursing and administrative leadership for accountability and compliance.

Evaluation:
Results of chart reviews and direct observations on the current process showed incomplete medication administration documentation by nurses. Once the electronic template was implemented, nurses found the documentation process easy. Compliance monitoring of documentation reached 100% within a month.

Implications for Practice:
Standardized process of medication documentation using electronic template will provide a reliable source of information to the healthcare team and outside reviewers. Omission and duplication of medications that can lead to serious adverse results can be prevented with the use of this template.