Adverse Drug Reactions in Moderate Sedation: Process Improvement During a Pandemic.

Background: A gap analysis identified the need for process improvement surrounding the identification and reporting of adverse drug reactions related to moderate sedation. A change to documentation was selected to address this gap. The challenge was disseminating the change in a meaningful way durin...

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Published in:Patient Safety (2689-0143) Vol. 5; no. 1; pp. 1 - 13
Main Authors: Bayne, Julia, Craft, Amanda, Ho, Alex, Riley, Jenna Mastromarino
Format: research tables/charts Journal Article
Published: Pennsylvania Patient Safety Authority Mar2023
Online Access:View this record in EBSCOhost
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      dt: Mar2023
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      pub: Pennsylvania Patient Safety Authority
      place: Harrisburg, Pennsylvania
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        atl: Adverse Drug Reactions in Moderate Sedation: Process Improvement During a Pandemic.
      aug:
        au:
          Bayne, Julia
          Craft, Amanda
          Ho, Alex
          Riley, Jenna Mastromarino
        affil: Penn State Health St. Joseph Medical Center
      sug:
        subj:
          COVID-19 Pandemic United States
          Conscious Sedation
          Adverse Drug Event Prevention and Control
          Quality Improvement
          United States
          Documentation
          Quality of Health Care
          Patient Safety
          Patient Education
          Human
          Quantitative Studies
          Descriptive Statistics
          Data Analysis Software
      ab: Background: A gap analysis identified the need for process improvement surrounding the identification and reporting of adverse drug reactions related to moderate sedation. A change to documentation was selected to address this gap. The challenge was disseminating the change in a meaningful way during a time of high census and limited staffing due to the COVID-19 pandemic. Complex adaptive systems theory was used to plan interventions in these conditions. Methods: Process improvement was organized into Plan-Do-Study-Act cycles guided by the gap analysis, literature, and aims. Quantitative data analysis was conducted using chart audits and a Likert survey. Interventions: Adoption of end-user-redesigned documentation was completed over time using one-on-one instruction, brief just-in-time education sessions at huddles, and ongoing feedback. Results: The survey results demonstrated a significant increase in adverse event knowledge (p=<0.01) and documentation confidence following just-in-time training (p<.01). Chart audits revealed an increase in identification of adverse events (p=0.03). Conclusions: Using a theory-based approach to implement process improvement is a successful way to create change in a challenging environment. Identification of adverse drug reactions related to moderate sedation increased, which is essential for evaluation and safe administration.
      pubtype: Academic Journal
      doctype:
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        tables/charts
        Journal Article
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    language: English
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