Situation: In March of 2022, a nurse made national headlines when she was criminally convicted for making a fatal medication error. This news caused concerns for all nurses around the country regarding medication administration safety. Vance spearheaded efforts in SDU for nurses to examine their own medication administration practices in the unit and discovered they lacked certain safeguards inpatient units had. The nurses recognized this placed them at a high risk for making med errors because they also experience heavy workloads that are time sensitive. Staff believed additional safeguards were needed to help reduce the risk for med errors, which would improve patient and staff safety. 
 
Action: Concerns were brought to the attention of Roseanna Camacho, Nurse Manager for SDU. Roseanna acknowledged the nurses’ concerns and was transparent in explaining how and why previous attempts to obtain safeguards such as BCMA and/or a profiled Omnicell medication system to be installed in SDU were unsuccessful in the past. Although attempts in the past were unsuccessful, she respected her staff’s concerns and encouraged Vance and staff to start a unit project to address safe medication practices in SDU. Thuan Nguyen, RN volunteered to assist with this project along with Vance. Because Roseanna had provided important information on the reasons why BCMA and a profiled Omnicell could not be obtained in SDU, Vance and Thuan were able to direct their focus on medication administration practices and Omnicell functions to help reduce the risk for med errors. Vance and Thuan collected and compared data related to medication administration practices between SDU and several other units. They performed evidenced-based research on best practices for medication safety regarding the Omnicell. They also reached out to VA Palo Alto HCS Medication Safety Subcommittee for guidance and advice on their best practices regarding the Omnicell. They collaborated with Pharmacy to obtain additional knowledge about the functions and capabilities of the Omnicell medication system at VA Puget Sound. After analyzing their data and assessing and evaluating the medication administration practices in SDU, they identified risk factors that could lead to med errors in SDU and proposed ideas to address them. They proposed changes to make the utilization of the non-profiled Omnicell to be safer and more efficient: Medications were added and removed, and par levels decreased and increased. Medications outside of SDU nurse’s scope to administer were removed to prevent inadvertent administration. Medications were added to ensure timely delivery of quality patient care. To reduce the chances of inadvertently retrieving the incorrect medication, the search function for medications in the Omnicell was changed from using only one character to a minimum of five characters. An electronic and physical copy of the inventory list for the Omnicell was made easily accessible for SDU nursing staff to refer to so that they are aware of all medications stocked in it. The knowledge of the contents in SDU’s medication Omnicell enables staff to be aware of what sound alike drugs are carried, and it also reduces the time spent away from patient care to check if a certain medication is carried in the Omnicell. They also created a PowerPoint presentation for the Clinical Practice Committee to review.
 
Outcome: Vance, Thuan, Roseanna, Elisa, and SDU staff collaborated to successfully manage risks for med errors in SDU. They demonstrated their commitment to serving the Veterans by taking proactive measures rather than reactive measures. Even though the safeguards of BCMA and a profiled Omnicell were unavailable to SDU, they came up with alternative solutions that were implemented to improve patient safety. They demonstrated how they strive for the highest quality care through their use of evidence-based research and practices. 

The solutions implemented by SDU can also be applied and implemented on a system wide level throughout VA Puget Sound, to reduce med errors and have a positive impact on patient and staff safety.  

Same Day Unit led by Thuan and Vance is continuously still striving for ways and solutions to improve patient care safety leading to high quality care and excellent patient satisfaction. This is well reflected in our multiple DAISY Award Nominations for Nurses. For the past year alone, we have had 2 DAISY Honorees and 3 DAISY Nominees and still counting! I am very honored to be a part of this team, and in my humble opinion, as their ANM, this team is simply the best! I wouldn't pass on this opportunity to nominate them and be recognized.