NUR 5310 Module 5 Implementation Plan Example

Going Live at 2 A.M.: An Implementation Plan for the External Medication History Screen That Keeps Night Admissions in View

Student Name

Master of Science in Nursing (MSN), Thomas Edison State University

NUR-5310: Nursing Informatics: Concepts and Issues

Mentor Name

Month Day, Year

Going Live at 2 A.M.: An Implementation Plan for the External Medication History Screen That Keeps Night Admissions in View

Earlier modules described the external medication history screen, its privacy controls and the duplicate therapy rule that misfired after it arrived. This paper turns to implementation: how the screen should be rolled out across our four medical units. The plan addresses readiness, workflow redesign, training, go-live support, monitoring for unintended consequences and the sustainment of the change. Its central commitment is that the plan be built around the shift that does most of the work, which on our units is the night shift, when about half of admissions from the emergency department arrive and when pharmacy and informatics support is thinnest.

Why Implementation Deserves Its Own Plan

Health information technology does not improve care simply by being installed. Ash et al. (2004) described errors that information systems can foster rather than prevent, falling into two groups: mistakes made while typing data in or finding it again, such as screens that fragment the clinical picture, and breakdowns in how clinicians coordinate and hand off work, such as software that assume work happens in a fixed sequence when real work is interrupted and shared. Han et al. (2005) reported that mortality among children transferred to one tertiary hospital rose from 2.80% to 6.57% in the months after a computerized order entry system was rapidly introduced hospital-wide over six days; the authors attributed part of the effect to workflow changes such as orders that could not be entered before a patient arrived. The study design cannot establish cause, but it is widely cited as a warning that speed and inattention to workflow carry risk.

Readiness and Workflow Redesign

The project team began with a current-state map of night admissions. A nurse admitting at 2 a.m. typically receives the patient from the emergency department, completes the admission assessment, and starts the medication history while also covering four or five other patients. The pharmacy technicians who complete histories on days are not on site at night. The new screen will present twelve months of external fills, which could help the night nurse but could also add a long list to review at the busiest point of the shift.

The future-state workflow therefore splits the task. The night nurse reviews the external list for medications needed in the next twelve hours, such as anticoagulants, insulin, antiepileptics and opioids, and documents which have been confirmed with the patient. The day pharmacy technician completes the full history by noon. The screen will show a banner stating whether the history is partial or complete, so that providers and later shifts know its status. This division was tested with night nurses in two simulation sessions before being adopted.

Training

Training will be role-specific and short. Night nurses, day nurses, pharmacy technicians and admitting providers will each complete a fifteen-minute module built on cases from their own workflow, followed by a hands-on session in the training environment. Night staff will be trained on nights, by trainers working those hours, rather than asked to attend daytime classes. Each unit will have two super-users per shift, including nights and weekends, who receive additional training and serve as first-line support. Tip sheets will be placed at each workstation, covering how to filter the list, mark a medication as not taken, and request pharmacy review.

Content will focus on decisions rather than clicks. Each case asks the learner to decide whether an external fill represents a current medication, which items must be confirmed before morning, and when to call pharmacy, because the risk in the new workflow lies in judgment more than in navigation. Trainers will collect questions from each session and feed them into the tip sheets and the go-live huddles.

Go-Live and Support

The units will go live one at a time, a week apart, rather than all at once, so that problems found on the first unit can be fixed before the next. For the first two weeks on each unit, an informatics nurse or super-user will be present around the clock, night hours included. A daily huddle on each shift will collect issues, and a shared log will record each problem, who owns it and when it was resolved. A rollback plan defines conditions, such as a system outage or a serious safety event linked to the screen, under which the unit returns to the previous process.

Communication runs alongside support. Before each unit goes live, the charge nurses will brief staff at every shift huddle for a week, and a short message will explain to admitting providers what the status banner means. After go-live, a weekly update will report the issues found, the fixes made and the measures so far, so that staff can see that problems they raise are acted on.

Monitoring for Workarounds and Unintended Consequences

Workarounds are signals, not just violations. Koppel et al. (2008) watched nurses at five hospitals and cataloged fifteen ways they bypassed barcode scanning, such as scanning patient barcodes affixed to carts, and thirty-one types of causes, many rooted in design and workflow rather than in carelessness. We expect similar behavior if the new screen does not fit the work: nurses copying the external list into free text, marking all items as reviewed without reading them, or postponing the history to the day shift entirely. The team will track how many admissions have a finished history by noon, the share of night admissions with high-risk medications confirmed within twelve hours, override data on the reconciliation alerts, staff feedback by shift and event reports involving admission medications.

Sustaining the Change

After the support period ends, the super-users will continue to meet monthly, and the reconciliation measures will be added to each unit's quality board. The plan includes a review at six months, when the team will decide whether further changes are needed, including any requested by night staff. Implementation is complete not when the screen is switched on, but when the people using it at 2 a.m. find it helps.

Sustainment also means planning for turnover. New hires and travel nurses will receive the role-specific module during orientation, and super-user roles will be refilled when people leave, so that the knowledge does not walk out the door with the original team.

References

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

Han, Y. Y., Carcillo, J. A., Venkataraman, S. T., Clark, R. S., Watson, R. S., Nguyen, T. C., Bayir, H., & Orr, R. A. (2005). Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics, 116(6), 1506-1512. https://doi.org/10.1542/peds.2005-1287

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616