We are better because of YOU! Background: Two Stop the Line (STL) events were called by front line staff to review nursing practices of high-alert medication administration.
Process: Nurses, pharmacy and care providers involved in the events along with the Medication Improvement Team were engaged in improving process. The multidisciplinary teams discussed the five rights of medication administration and outlined a defined process for MGH. Staff involved in the cases above spoke with their teams at staff meetings about the importance of the nursing independent double check.
Outcome: Ensure patient safety by defining a standardized Double Check Process from the Medication Improvement Team for high-alert medications (Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation). Purchase of additional barcode scanners to support RN workflow and the medication administration process. Enhanced because frontline staff took accountability for their actions and recognized they could be part of the solution.
