1. Part 1: Agenda and Outcome
This presentation is an in-service learning session that focuses on a safe medication
administration improvement plan. We are going to examine the root cause analysis for
medication errors; and the significance of communication between healthcare workers and
patients in the prevention of medication errors. We are going to learn how to enhance patient
engagement and communication in order to prevent medication errors. This learning / training
session focuses on a concept or rather the skill known as the ‘Teach-back Method’ for the
prevention of medication errors.
Part 2: Safety Improvement Plan
Why is it important that we develop a safety improvement plan for medication errors?
There are several reasons for developing a safety improvement plan. One of the reasons is
because of the presence of medication errors. The FDA receives approximately 100,000 reports
on medication errors each year (U.S. Food and Drug Administration, 2019). There are
approximately 700,000 emergency department visits due to adverse drug events (Agency for
Healthcare Research and Quality [AHRQ], 2019). Additionally, 100,000 hospitalizations occur
each year due to medication errors or adverse drug events (AHRQ, 2019).
More importantly, medication errors are in themselves a preventable harm. There is no need for a
patient to suffer due to medication errors. The National Coordinating Council for Medication
Error Reporting and Prevention, a medication error is defined as “any preventable event that may
cause or lead to inappropriate medication use of patient harm while the medication is in the
control of the healthcare professional, patient, or consumer” (FDA, 2019).

2. Proper communication is very important in the prevention of medication errors. Proper or
effective communication allows for complete medication reconciliation during prescription (Da
Silva and Krishnamurthy, 2016). Approximately one-third of the US population take 5 or more
medications (AHRQ, 2019). Effective communications allows the physician to gain complete
information from the patient on all type of medications that they are taking and this allows the
physician to create a plan that prevents occurrence of adverse drug events from certain drug
interactions. Enhanced patient understanding of prescription instructions prevents medication
errors or lack of adherence to the treatment regimen (Da Silva and Krishnamurthy, 2016).
Problem / Root Cause Analysis
One of the main causes of medication errors is poor communication and poor patient engagement
(Da Silva and Krishnamurthy, 2016; Salar, Kiani, and Rezaee, 2020). Poor communication and
lack of patient engagement leads to lack of information sharing, for example of other
medications that the patient may be taking. Lack of proper communication and information
sharing impairs medication reconciliation and this increases the risk for adverse drug events (Da
Silva and Krishnamurthy, 2016; Salar, Kiani, and Rezaee, 2020).
An additional cause for medication errors is lack of assessment of patient’s comprehension of the
information that they have received on their medication (Salar, Kiani, and Rezaee, 2020;
Wondmieneh et al 2020). Doctor-physician miscommunication is a common occurrence in
healthcare that has been given limited attention; the doctor or healthcare worker assumes that
since they have explained the medications and prescription instructions that the patient
immediately understands all the information. There is a high need for assessment of patients’

3. comprehension of the information that they receive to ensure that they understood all the
instructions.
It is important to assess patients’ comprehension of medication instruction because there is an
overall low health literacy level among the public. Based on the last survey that was conducted
on health literacy, only 12% of adults in the US have health literacy (National Center for
Education Statistics, 2006). The Center for Health Care Strategies (2013) puts the health literacy
at 36%, which is still less than half of the population. Low health literacy causes patients to be
unable to understand prescription labels (Center for Health Care Strategies, 2013; Wali et al
2016). In effective communication and lack of comprehension of prescription instructions causes
medication errors (Wali et al. 2016).
The U.S. Department of Health and Human Services (2021) defines health literacy as “the degree
to which individuals have the capacity to obtain, process, and understand basic health
information needed to make appropriate health decisions.”
The Proposed Plan
The plan for improving medication safety and assessment of patients’ comprehension involves
the Teach-back Method.
The plan: Teach-back Method.
The aim of this plan is to enhance healthcare worker-patient engagement and communication.
The plan also aims to reduce prescription mistakes and medication errors.
The Teach-back Method is an evidence-based strategy for improving engagement and reducing
medication errors (Callaway et al. 2018; Kornburger et al. 2013). It involves evaluation of

4. patient comprehension of the information that they have received by asking them to explain in
their own words what they have learnt.
Part 3: Audience’s Role and Importance
Role
The main role of the audience is to learn about the Teach-back Method and participate in the
training. They are expected to become advocates for the Teach-back Method after undergoing
the training. Consequently, they will help to educate other healthcare professional within their
area of practice or unit/ward on this method.
Their Importance
This audience is critical to the success of the improvement plan on medication administration
and prescription. The audience interacts with patients and as such they are significant in ensuring
that there is improved communication with patients and that there is enhanced patient
understanding of medications that they are prescribed.
The audience is critical to the success of the improvement plan on medication administration and
prevention of errors as registered nurses are responsible for administering education. Nurses are
also responsible for patient education and act as advocates for patients; the presence of nurses
ensures that the improvement plan is a success as the nurses will take the measures to promote
patient safety and prevent occurrence of medication errors.
Physicians also make part of the audience and they are important for the success of this
improvement plan on prevention of medication errors as they prescribe medications and are
important for reconciliation of medication.

5. The ultimate goal / role of the audience will be to prevent ineffective communication between
healthcare workers and patients concerning medications, ensure that there is enhanced
understanding of medications by the patients and ultimately prevent medication errors.
How their work could benefit from embracing their role in the plan
The audience will benefit from the session and training by having improved communication with
patients and their carers. The audiences’ work will benefit from improved health literacy of
patients; several studies show that empowered/educated patients promote safety in health care.
Patient-centered care is associated with a decrease in medication errors and other safety issues in
healthcare (Salar, Kiani, and Rezaee, 2020.; Kornburger et al. 2013).
The audience will be equipped to reduce or prevent medication errors and lack of compliance to
prescription from discharged patients that results from lack of understanding of the medication
and prescription instructions.
Part 4: New Process and Skills Practice
The main process and skill that is involved in this improvement plan is communication. It
involves evaluation of patients’ comprehension of the information that they have received by
asking them to explain/repeat in their own words what they have learnt. The new skill is the
Teach-Back Method.
Activities
Distribute visual aids – 1 page document on “10 Elements of Competence for using Teach-back
effectively”.

6. Go through the material and encourage audience to ask question on how to conduct Teach-back
Method.
Watch video – Encourage to ask question.
Possible questions:
What is the purpose of Teach-back method?
It is a way of ensuring that the patient has completely understood the information that they have
been taught on medication and prescription instructions (Callaway et al. 2018; Kornburger et al.
2013).
What is the most important part of the Teach-back method during a real practical session?
The most important part of the Teach-back Method is asking for the patient to teach you back.
An additional important aspect is to be very respectful of the patient and avoid shaming the
patient or appearing judgmental on their lack of health literacy.
Demonstration of Teach-back with 2 audience members
Practice Teach-back method among each other.
Practical Session
Move to the practical part of the training session.
Using members of the public – with no medical background; this is because low health literacy
levels is one of the main factors that affects patients’ comprehension of medication information
(NCES, 2006; Wali et al. 2016).
Participants will practice with real/possible patients.

7. The audience will educate participants/‘patients’ on at least 3 medications. This is because the
more medications that are involved the more important the patients’ comprehension is, to the
prevention of medication errors.
Then ask for them to do Teach-back.
Soliciting Feedback
Feedback is an important of part of improvement plan in-service presentations. It allows the
presenter to improve the material such that it becomes useful to the staffs. Feedback also allows
the presenter to develop their communication skills for future projects.
One of the ways in which I will solicit feedback on the presentation from the audience is by
asking for feedback at the end of the session. I would ask them to point out the strengths and
areas for improvement on my presentation skills and training session itself.
Additionally, I will send them evaluation forms after the session for them to evaluate the session
and my skills. The reason for this additional method is that the evaluation form allows for
anonymity, which allows for more honest feedback. The participants can also include as much
detail as they want on the evaluation, as they are not constrained by the time limit of the timed
training session.
I could also solicit feedback from other professionals who have knowledge on Teach-back
Method or patient education. They can provide valuable feedback on the concept of the Teach-
back method and how to best teach it.
How will I integrate the feedback in future?

8. There are several ways in which I can integrate this feedback for future improvements. I could
adjust the length of the training activities to allow for more or less time for training depending on
the feedback. I can use the feedback to modify the content of the session by ensuring that it is
more clear, less confusing, and that it serves the purpose of educating my colleagues on a new
skill or concept. I would use the feedback to ensure that the content is simple, straight to the
point, comprehensive, and educative. Remove any fluff or use more resources and visual aids to
ensure that the presentation is not boring. I could ensure that the future presentation uses more
resources so that it is able to capture and sustain the attention of the audience. Depending on the
feedback, I could take a more practical approach in the education session or allow more audience
participation rather than on me solely doing the presentation.

9. References
Agency for Healthcare Research and Quality, 2019. Medication Errors and Adverse Drug
Events. Available from: CITE [Accessed 28th January 2022].
Callaway, C., Cunningham, C., Grover, S., Steele, K.R., McGlynn, A. and Sribanditmongkol, V.,
2018. Patient Handoff Processes: Implementation and Effects of Bedside Handoffs, the
Teach-Back Method, and Discharge Bundles on an Inpatient Oncology Unit. Clinical
Journal of Oncology Nursing, 22(4), pp.421-428.
Center for Health Care Strategies, 2013. Health Literacy Fact Sheets. Available from:
https://www.chcs.org/resource/health-literacy-fact-sheets/ [Accessed 28th January 2022].
Da Silva, B.A. and Krishnamurthy, M., 2016. The alarming reality of medication error: a patient
case and review of Pennsylvania and National data. Journal of community hospital
internal medicine perspectives, 6(4), p.31758.
Kornburger, C., Gibson, C., Sadowski, S., Maletta, K. and Klingbeil, C., 2013. Using “teach-
back” to promote a safe transition from hospital to home: an evidence-based approach to
improving the discharge process. Journal of pediatric nursing, 28(3), pp.282-291.
National Center for Education Statistics, 2006. The Health Literacy of America’s Adults Results
from the 2003 National Assessment of Adult Literacy. Available from:
https://nces.ed.gov/pubs2006/2006483_1.pdf [Accessed 28th January 2022].
Salar, A., Kiani, F. and Rezaee, N., 2020. Preventing the medication errors in hospitals: A
qualitative study. International Journal of Africa Nursing Sciences, 13, p.100235.

10. U.S. Department of Health and Human Services, 2021. Health Literacy. Available from:
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-
health/interventions-resources/health-
literacy#:~:text=The%20U.S.%20Department%20of%20Health,able%20to%20read%20a
nd%20comprehend [Accessed 28th January 2022].
U.S. Food and Drug Administration, 2019. Working to reduce medication errors. Available
from: https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-
reduce-medication-errors [Accessed 29th January 2022].
Wali, H., Hudani, Z., Wali, S., Mercer, K. and Grindrod, K., 2016. A systematic review of
interventions to improve medication information for low health literate
populations. Research in Social and Administrative Pharmacy, 12(6), pp.830-864.
Wondmieneh, A., Alemu, W., Tadele, N. and Demis, A., 2020. Medication administration errors
and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis
Ababa, Ethiopia. BMC nursing, 19(1), pp.1-9.