< Previous18 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com I MMOBILITY compromises almost every sys- tem in the body. Studies show that adults who were ambulatory before hospital admission spend up to 83% of their time lying down while in the hospital, and more than a third of hospitalized adults 70 years and older are dis- charged with a major new disability that wasn’t present on admission. Mobilizing patients safely and consistently is challenging. Accurately assessing mobility status allows healthcare providers to monitor improvements and deterioration and apply in- terventions to mobilize patients, even when deficits are present. The result can be progress toward physical independence; at a minimum, it maintains patients’ strength and decreases risks associated with bedrest. This article introduces the Bedside Mobility Assessment Tool 2.0 (BMAT 2.0), revised from BMAT 1.0, which was created to identify pa- tient mobility function deficits and guide the healthcare team in selecting equipment to safe- ly handle and mobilize patients. BMAT 2.0 is most effective when documented in the elec- tronic health record (EHR) and clearly commu- nicated with all staff. BMAT aligns with the American Nurses As- sociation’s (ANA’s) Safe Patient Handling and Mobility: Interprofessional National Standards Across the Care Continuum by promoting mobilization techniques. The tool promotes healthcare worker safety and early and fre- quent mobilization, which improves patient safety. The Bedside Mobility Assessment Tool 2.0 Advancing patient mobility By Teresa Boynton, MS, OTR, CSPHP; Dee Kumpar, BSN, RN, MBA; and Catherine VanGilder, MBA, BS, MT, CCRAMyAmericanNurse.com July 2020 American Nurse Journal 19 BMAT origin In 2003, Boynton (lead author of this article) saw the need for a mobility assessment tool and began searching for one nurses could use to determine patients’ current mobility status and would help standardize safe patient han- dling and mobility (SPHM) equipment (espe- cially patient lifts) use. Development included networking with nurses from different hospi- tals and piloting the tool to assess its feasibility and utility. Validation In 2012-2013, BMAT 1.0 was validated for con- tent and construct, and for inter-rater reliabili- ty by a healthcare team at Banner Baywood Medical Center in Mesa, AZ. The tool was cre- ated in the Banner Health system EHR and linked to the fall risk assessment (Morse Fall Scale) on the Adult Mobility and Fall Risk As- sessment screen and to the skin assessment (Braden Scale). Nurses who completed an early BMAT 1.0 pilot study on a 60-bed medical telemetry unit found that the tool took the guesswork out of determining a patient’s mobility status and choosing SPHM equipment. Findings in- cluded decreased nurse injuries and patient falls. Nurses reported increased awareness of changes in patients’ status during a shift and improved confidence using SPHM lifts and getting patients out of bed more frequently because they no longer relied on physical and occupational therapists. BMAT 1.0 has been implemented at many hospitals throughout the United States and in- ternationally. Nursing implications include timely referrals to rehabilitation services; im- proved communication among nurses, aides, physical and occupational therapists, and an- cillary services (radiologists, transporters) re- garding SPHM practices and safe patient trans- fer methods; and better implementation of ANA SPHM Standard 6 (integrate patient-cen- tered SPHM assessment, plan of care, and use of SPHM technology). BMAT 2.0 BMAT 2.0 incorporates new knowledge devel- oped over 5 years of BMAT 1.0 use. It clarifies how to perform assessments and determine pass or fail; the nurse’s role in assessing, strengthening, and progressing patients; pro- gression from Level 3 to Level 4; and the use of walkers, canes, crutches, and prosthetic legs and progressing patients who use these aids. BMAT 2.0 also addresses bilateral nonweight- bearing patients and bed rest orders and focus- es on previous level of function (PLOF), dis- charge planning, and goals for ambulating patients who pass all four assessments. BMAT 2.0, which takes about 2 minutes to complete, typically is performed by nurses on patient admission, once per shift, and with any significant change in a patient’s status. It empowers caregivers to ACT: •Assess for mobility level in “safe mode.” •Coordinate strategies for strengthening. •Target the right piece of equipment to ad- vance mobility. The tool defines four levels of mobility. Each level has a physical task aimed at assess- ing a patient’s strength, coordination, balance, tolerance, and ability to follow directions. When patients can perform the task, they ad- vance to the next level; if they can’t, they stay at the current level. If the patient is respon- sive, the assessment can be completed as part of routine physical and cognitive screenings. (Download the full BMAT 2.0 at myamerican- nurse.com/?p=66915 .) Level 1 assessment Level 1 evaluates core strength, sitting toler- ance, balance, and hemodynamic stability in response to sitting upright. Sit and shake: Ask the patient to pivot from a semireclined position (head of bed ≥ 30 degrees) to the edge of the bed and main- tain an unsupported seated balance for up to 1 minute (to allow fluid shifts and other com- pensatory changes to occur). Then ask the pa- tient to reach across the midline with one hand and shake your hand; have the patient repeat with the other hand. Assess: Can the patient maneuver to an upright seated position and maintain unsup- ported seated balance while reaching across the midline? •Unsupported sitting engages core muscles and back extensors. •Sitting upright assists with fluid shifts (with bedrest, about 1 L of fluid moves from the legs to the chest). •Sitting upright aids ribcage expansion and breathing. Patients who sit without getting tachy- cardic, diaphoretic, or light-headed, and can 20 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com reach across and shake your hand can pro- ceed to Level 2 assessment. Note: Patients who are nonresponsive or have a strict bedrest order are automatically Level 1 and should be mobilized following pro- gressive mobility protocols. A provider’s “strict bedrest” or “bedrest” order may require clarifi- cation if the order is inconsistent with nursing responsibility expectations. Patient mobiliza- tion is within the scope of nursing practice, and nurses are expected to evaluate patients’ needs and advance mobility to avoid immobility risks and complications. Safe mode: Consider safe mode for pa- tients who can’t perform Sit and Shake (for example, a patient with a large abdominal in- cision), for patients you’re not sure can inde- pendently maneuver to a seated position at the edge of bed and sit unsupported, and for patients who may slide off the bed. (See Safe mode.) How do I mobilize and progress pa- tients who can’t perform Sit and Shake? Level 1 patients require appropriate SPHM equipment for tasks such as repositioning/ boosting, turning, limb holding, and bed-to- chair transfers. Consider calf pump exercises to help progress these patients, prepare them for the Level 2 assessment, assist with circula- tion, and prevent contractures. Level 2 assessment Level 2 evaluates a patient’s ability to engage leg and foot muscles. It assesses leg strength and foot-drop contracture deformity and is a precursor to weight-bearing. Stretch: While the patient is sitting upright and unsupported on the side of the bed or in a chair, instruct the patient to extend one leg, straighten the knee (knee remains below hip level), pump the ankle (dorsiflexion/plantar flexion) at least three times, and repeat with the other leg and ankle. Assess: Can the patient straighten the knees and pump the ankles? •This maneuver evaluates patient control and leg muscle (quadriceps and calf muscles) strength. •Pumping the ankles engages the calf mus- cles, which assists with venous blood return (leg muscles, especially calf muscles when they contract, play an important role in compressing major leg veins and ensuring adequate blood return to the heart). When done before the patient stands, calf pump exercises can decrease the risk of orthosta- tic hypotension and falls. •Achilles tendon shortening is one of the most common contractures that occurs with bedrest. Pumping the ankle assesses for this contracture and ability to move the ankles. •Extensor muscles (for example, quadriceps, which have a primary postural role) are one of the first groups of muscles compro- mised by bedrest. These muscles are neces- sary for both standing and walking. Pa- tients who can't perform Stretch won’t be able to safely stand or walk. Assessing can prevent a possible fall. Patients who sit without getting tachy- cardic, diaphoretic, or light-headed, and can extend their leg/straighten their knee and pump their ankle three times (one leg/ankle and then the other) can proceed to Level 3 as- sessment. Safe mode: Consider performing Stretch with the bed in chair position or by support- ing the patient in a walking/ambulation vest or pants and a lift at the edge of the bed. How do I mobilize and progress pa- tients who can’t perform Stretch? Level 2 patients typically require the same type of SPHM equipment as Level 1 patients; however, because they have adequate seated balance, Level 2 patients can participate to a greater ex- tent than Level 1 patients. When working to progress Level 2 patients, a powered sit-to- stand lift, which allows the patient to safely as- sume an upright position and bear weight through one or both legs, may be appropriate. Other leg-strengthening exercises can be in- corporated into the patient’s care plan, along with increased calf pump exercise repetition. Level 3 assessment Level 3 evaluates the patient’s ability to stand, tolerate standing, and maintain standing bal- ance, which are precursors to ambulation. Stand: While the patient is sitting upright unsupported on the side of the bed or in a chair, with feet positioned about shoulder- width apart, instruct the patient to move from a seated position to standing upright. Patients should shift their weight forward while raising the buttocks from the surface and rising. Assess: Can the patient shift forward, rise, and maintain standing balance for up to 1 minute? MyAmericanNurse.com July 2020 American Nurse Journal 21 •Stand evaluates the patient’s leg muscle con- trol, dynamic balance, and strength to rise. •Standing upright for up to 1 minute allows fluid to shift and other compensatory changes to occur. Most patients who exhib- it orthostatic hypotension do so in the first minute of standing, which is the rationale for standing for up to 1 minute for this as- sessment. •Guide patients who become light-headed or can’t tolerate standing to sit down. Patients who can stand without becoming tachycardic, diaphoretic, or light-headed, and who have the cognitive ability to stand can proceed to Level 4 assessment. Safe mode: To assess Stand in safe mode and progress the patient, consider using a sit- to-stand lift to determine how the patient tol- erates moving from sitting to standing and weight-bearing. •If the patient tolerates standing with the use of a sit-to-stand lift, consider repeating Level 3 assessment without the lift or con- sider further strengthening exercises and referral to physical therapy (PT). •Consider use of the patient’s walker, cane, crutches, or prosthetic leg(s) consistent with best practice and safe use guidelines during the standing assessment. How do I mobilize and progress patients who can’t perform Stand? Level 3 patients may require the same type of SPHM equip- ment as Level 2 patients for tasks such as quick transfers from bed to toilet. Consistent with best practice guidelines, use the patient’s walker, cane, crutches, and prosthetic leg(s) to complete stand. If the patient passes Stand, continue to Level 4 Assessment using aides as needed. Level 4 assessment Level 4 evaluates the patient’s ability to step in two parts: march in place and advance step and return with one foot then the other. This is a precursor to ambulation. Step: While the patient is standing at the side of the bed or by a chair, ask the patient to march in place using small steps (not lifting knees up high) for three repetitions. If the pa- tient successfully completes marching in place, ask the patient to step forward with the right foot then return to the starting position; repeat with the left foot. Assess: Can the patient shift weight from one foot to the other and maintain balance side-to-side and forward and back? •Step assesses patient leg muscle control and dynamic balance. •Step allows fluid to shift and other com- pensatory changes to occur. •Guide patients who become light-headed or can’t tolerate the Step maneuvers to sit. •Patients who can pass marching in place but can’t perform advance step and return with one or both feet should be guided to sit; request a PT consult. To avoid potential falls, keep the patient close to the bed or chair; patients shouldn’t independently leave the side of the bed or chair until they demonstrate the ability to back up. Patients who can Step without becoming tachycardic, diaphoretic, or light-headed, and who have the cognitive ability to Step can proceed to activities to improve endurance and ambulation confidence. Safe mode: To assess Step in safe mode and progress the patient, consider positioning the bed in chair position and use end-of-bed egress after fitting the patient with a walking vest or pants with a mobile lift. Another op- tion is having the patient sit at the side of the bed and using a walking/ambulation vest or pants and ceiling lift. Using either technique, instruct the patient to complete Step. How do I mobilize and progress pa- tients who can’t perform Step? Level 4 pa- tients may require the same type of SPHM equipment (for example, a stand aid) as those used with Level 3 patients for tasks such as quick transfers from bed to toilet during the night. Following good practice guidelines, initially complete Step in safe mode using a walking/ambulation vest or pants and a lift; consistent with best practice, use the patient’s walker, cane, crutches, or prosthetic leg(s) to complete the maneuver. Patients who perform and pass both por- tions of Step, with or without an aid, can progress through discharge planning. How do I mobilize and progress patients who have passed all four assessment levels? To meet discharge goals, patients who have passed all four assessment levels may still need to use a lift with a walking/ambulation vest or pants to increase endurance and distance walked and to reduce fall risk. In addition: •Continue to address medical issues and sta- bility as needed while improving or main-22 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com taining mobility; evaluate other medical con- ditions and treatment plans before discharge. •Coordinate with PT and the care coordina- tion team when considering discharge planning goals, destination, and equipment needs. (Remember, discharge planning be- gins on the day of admission.) •Compare preadmission/prior status, includ- ing ability to perform activities of daily liv- ing, to discharge status; i.e., PLOF com- pared to post-acute functional status. •Use a multidisciplinary approach to review rehabilitation goals and ensure they’ve been met. •Continue to complete BMAT 2.0 assess- ments per protocol. With any change in the patient’s ability to complete an assessment level, adjust mobility level and goals as needed. Vital indicator Mobility is a vital indicator of patient deteri- oration or improvement. Proper assessment using BMAT 2.0 can help predict mobility changes early so they can be addressed. In addition, it encourages evaluating patients’ pre-admission status and setting functional mobility goals, as well as promoting dis- charge planning that begins on the day of admission. Standardizing nursing practice, processes, and procedures for SPHM equipment use pro- motes caregiver safety, reduces nursing care variability, results in better patient outcomes, and aligns with ANA’s standards. AN Visit myamericannurse.com/?p=66915 to view other tools that have been used for mobility assessment and a list of references. Teresa Boynton is a clinical consultant at Mobility Consulting and Presentations, LLC, based in Loveland, Colorado. Dee Kumpar is the clinical marketing manager for patient support systems at Hill- Rom. Catherine VanGilder is a senior manager of medical affairs for patient support systems at Hill-Rom. Depending on the patient’s current condition, consider safe mode for each assessment level. Below are examples of safe mode options for each level for a patient who’s had abdominal surgery. To view other patient scenarios, visit myamericannurse.com/?p=66915. Patient Level 1 assessment Level 2 assessment Level 3 assessment Level 4 assessment scenario Sit and Shake Stretch Stand Step Post abdominal surgery Safe mode • Patient is unable to move to side of bed without assistance • Nurse raises head of bed and monitors patient • Patient tolerates well and nurse slides sling behind patient • Nurse attaches sling to lift and uses it to move patient to edge of bed • Nurse instructs patient to sit upright un- supported by sling and complete Sit and Shake • Patient passes/ demonstrates Sit and Shake and progresses to Assessment 2 • Patient remains in sling attached to lift • Nurse instructs patient to extend one knee and complete ankle pumps three times and repeat with other leg • Patient passes/ demonstrates Stretch and progresses to Assessment 3 • Nurse detaches sling from lift and moves lift out of the way • Nurse brings in powered sit-to-stand lift, fits sling/vest to patient, and attaches sling/vest to lift • Nurse uses lift to bring patient to upright standing position • Patient tolerates up- right standing position for 2 minutes while nurse takes standing blood pressure and heart rate • Patient passes Stand with use of lift and progresses to Assessment 4 • Nurse uses sit-to-stand lift to move patient back to bed or chair, detaches sling/vest, and moves lift out of the way • Nurse positions ambu- lation pants and attaches them to mobile lift • Patient is instructed to stand as nurse coordi- nates raising lift hanger bar and positioning lift armrests/handholds • Patient completes Step (march in place and advance step and return) • Patient demonstrates/ passes Step while attached to lift and progresses to walking independently in room without lift • Patient continues to walk in hallway using ambu- lation pants and lift, increasing distance, strength, tolerance, and confidence; consider discharge goalsMyAmericanNurse.com July 2020 American Nurse Journal 23 Lean on me Taking care of nurses’ mental health during the COVID-19 pandemic LEADING THE WAY Tari Dilks T HE COVID-19 PANDEMIC is pushing nurses to their limits. The American Nurses Association (ANA) spoke with Tari Dilks, DNP, APRN, PMHNP-BC, FAANP, president of the American Psychiatric Nurses Association (an ANA premier organizational affiliate), about the men tal health challenges nurses are facing, the role of nurse leaders, and resources for coping during the crisis. How can leaders support nurses’ mental health during the pandemic? Begin by taking care of your own mental health. Not only will you be a role model, but self-care will help you to be more calm and in control to provide leadership and support for your team. To support nurses, encourage your staff to talk about their feelings rather than hold in their stress and anxiety. Interventions may be needed. Simply stopping to ask nurses how they’re feeling can help someone who’s strug- gling. You don’t have to solve problems—just be there to listen. Also, you can make sure nurses have time and a location to decompress. Meditation or spir- itual practices are beneficial. Even 15 minutes can help. And let nurses know they’re appreci- ated for who they are and what they’re doing. How can nurses cope with being pulled in all directions and worrying about health risks to themselves? Recognize that what you’re feeling is normal. Figure out what you can control, and focus on those things. Nurses are not good at self-care. But we need to realize that if we don’t stay somewhat healthy, we can’t be there for oth- ers—our patients, families, and community. In addition to eating healthy and staying hydrated, find time to exercise. If not daily, maybe three times a week. It will increase endorphins and help alleviate stress. When nurses begin to feel symptoms of burnout, that’s the signal to make a change. Consider taking a break from the media, spend- ing time with family, and engaging in an activity that provides enjoyment whenever possible. What can be done to help nurses manage grief and loss during a pandemic? Coronavirus has made caring for those who are dying so difficult. Patients are physically sepa- rated from their loved ones. To help with your own grief, try to find a way to honor the per- son who died. Don’t ignore the feelings of grief. Journaling can be helpful, and expressing your feelings to others is always a good idea. What can we expect in terms of long- term mental health needs for nurses? In studies of healthcare providers during the severe acute respiratory syndrome (SARS) out- break, 10% had post-traumatic stress disorder. Three years later, 40% of those still had symp- toms. We have to do what we can to protect nurses who are affected. I think we will see significant changes in healthcare geared toward mental health. Nurses are resilient, and focusing on the positive things that come out of this crisis helps—whether it’s spending time with our families, saving a life, or sharing experiences with our colleagues and friends. We must find the time to stop, slow down, and celebrate the joys in our lives. AN Interview by Elizabeth Moore, MFA, a writer at ANA. • American Psychiatric Nurses Association: Managing stress & self- care during COVID-19: Information for nurses (apna.org/Managing Stress) • National Alliance on Mental Illness: Connection Recovery Groups (nami.org/Support-Education/Support-Groups/NAMI-Connection) • U.S. Department of Veterans Affairs: Veterans PTSD Coach free app (mobile.va.gov/app/ptsd-coach) • Crisis lines: •911 •National Suicide Prevention Lifeline: 800-273-8255 •Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress helpline: 1-800-985-5990, or text TalkWithUs to 66746 ResourcesT HE SAME MINDFULNESS we practice for our health and self-care can be translated into a safety strategy. (See Mindfulness defined.) Brief mindfulness interventions, which can help you manage your reactions to stressful situations, are associated with reduced anxiety and errors, and improved team relationships, employee engagement, and quality and safety. This article describes a mindfulness strategy implemented to reduce errors in medication preparation and administration. Medication errors During a typical hospital shift, nurses spend a great deal of time managing medications— checking lab values; reviewing orders with providers; locating, preparing, and double- checking medications; providing patient and family education; assessing patients; adminis- tering medications via multiple routes; and documenting and monitoring effects. Medica- tion management complexity can increase with patient acuity, an individual nurse’s pa- tient assignments, and medication number and risk level (for example, I.V. opioids, in- sulin, heparin, and chemotherapy are high- risk medications). Given this complexity, patients experienc- ing an average of one medication error per day, as reported by Aspden and colleagues and the Institute of Medicine, isn’t surprising. Many of these errors go unrecognized, even by the nurse, and most don’t result in harm. Common human factors that can result in ad- ministration errors include rushing, multitask- ing, and functioning on autopilot. Nurses in- terviewed in a medication safety pilot study conducted by Durham and colleagues said they usually were rushing when a near miss or actual error occurred. (See Medication er- rors and the human factor.) Role of mindfulness in medication safety We need to shift from valuing perceived effi- ciency over safety. For example, in some healthcare settings, “no interruption zones” are created near medication preparation areas, and nurses are empowered to not respond to interruptions from others when they’re fo- cused on medication preparation. Although 24 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com Mindfulness for medication safety Break the cycle of rushing and multitasking. By Marianne L. Durham, DNP, RN, CPPS HEALTHY NURSE Simply stated, mindfulness, which is learned via meditative exercises, is paying attention without judgment to what’s happening in the current moment. Mindfulness-based stress reduction, developed by Jon Kabat- Zinn, PhD, at the University of Massachusetts Medical School, is the most well-known intervention. The 8-week program focuses on teach- ing students how to attend to body sensations such as the breath to bring their attention back when the mind wanders. Variations of the program have been used to: • treat substance abuse and depression • foster healthy eating • improve firefighters’ well-being. Mindfulness definedMyAmericanNurse.com July 2020 American Nurse Journal 25 safety systems are important to help prevent errors, unexpected events can occur that even the most stringent systems, policies, and pro- cedures can’t catch. Mindfulness strategies can prepare nurses for unexpected events and help them achieve reliable outcomes. They’ll expect error and be vigilant for it, hoping to learn and improve, and they’ll report near misses so they can be ana- lyzed for future prevention. Consider Captain Chesley “Sully” Sullenberger III. He followed protocols but also used cognitive awareness as part of his decision-making when he landed his plane in the Hudson River after both engines were disabled by a bird strike; all 155 people aboard survived. Mindfulness practices help us switch from operating on autopilot to being aware and taking a thoughtful approach to clinical deci- sion-making and error interception. This state of awareness, coupled with safeguards such as barcode medication administration and in- dependent double checks for the highest risk medications, can reduce preventable error. To help promote mindfulness as a standard practice, preceptors and nurse leaders can model the strategies for students and demon- strate that they’re a valued behavior. Teaching nurses a brief mindfulness strategy As part of Durham’s pilot study, 99 acute and critical care nurses were taught a brief strategy to help them focus on one breath as part of medication safety. The strategy was taught in 30-minute small-group sessions via a medita- tion exercise. Using elements from Kabat- Zinn’s mindfulness-based stress-reduction program, participants were trained to perform an awareness scan of their body from head to feet and then focus on the sensation of the breath. With that training as the foundation, nurses were instructed to focus on one breath just before preparing medication and again before administering it to help them be fully present for the tasks. Some scholars describe being fully present as “watchfulness” or “a lu- cid awareness of each experience that pres- ents itself.” The goal of this cognitive state of sustained attention is to help improve nurses’ awareness and behaviors to improve patient safety outcomes. (See Mindfulness checklist.) When the nurses were first approached about the pilot mindfulness strategy, some Human factors associated with medication errors include rushing, multi tasking, and running on autopilot. Rushing Systems such as hard stops in barcode medication administration and the electronic health record are designed to safeguard patients and cli- nicians, but they can’t prevent a nurse who’s rushing from inadvertent- ly grabbing and delivering a look-alike medication. And nurses who are in a hurry may choose to skip safety steps such as scanning a med- ication or a patient ID. Time pressure can exist in any setting; for ex- ample, when a nurse is administering medications to a patient and a transporter says the patient has to leave immediately for a scheduled procedure or when multiple vaccinations need to be administered within a 15-minute time slot to children in a clinic. Multitasking Multitasking is a highly prized skill that many nurses would agree is central to their job; however, it is a risk to patient safety. Nurses may not be aware of the risk of error when, for example, they discuss a patient with the provider while preparing medications. Medication administration complexity requires that it be a single task respected by coworkers and supported by nurse leaders. Autopilot Administering medications without being fully aware if it’s appropri- ate for the patient—autopilot—is difficult to identify. Consider airline pilots. An article in The Wall Street Journal describes how their skills decrease with the use of the autopilot function and increase with the amount of time spent flying manually. An overreliance on automa- tion is linked to crashes by pilots reacting after an emergency rather than taking proactive action to avoid it. Similarly, nurses may use barcode scanning and trust that it’s correct but still draw up and administer the wrong dose of the medication if they aren’t paying attention. Medication errors and the human factor26 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com were concerned that it would add more work. However, the strategy involves focusing on on- ly one breath, and nurses were reminded that breathing is something they’re already doing. Break the cycle Mindfulness practices can help increase nurs- es’ awareness and cognition and help break the cycle of rushing, multitasking, and running on autopilot. If we approach medication errors as a common reality, mindfulness may help us detect and prevent them, improve the system, and remain vigilant for the unexpected. AN Marianne L. Durham is a clinical assistant professor in the Depart- ment of Health Systems Science at the University of Illinois at Chicago (UIC) College of Nursing and a faculty advisor at UIC Insti- tute for Healthcare Improvement Open School Chapter in Chicago. References Agency for Healthcare Research and Quality. PS Net: Pa- tient Safety Network. Patient Safety Primer: Medication administration errors. September 2019. psnet.ahrq.gov/ primer/medication-administration-errors Aspden P, Wolcott J, Bootman JL, et al., eds. Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007. Carr N. Automation makes us dumb. Wall Street Journal. November 21, 2014:C1, C2. Creswell JD. Mindfulness interventions. Annu Rev Psy- chol. 2017;68:491-516. Daigle S, Talbot F, French DJ. Mindfulnessbased stress reduction training yields improvements in wellbeing and rates of perceived nursing errors among hospital nurses. J Adv Nurs. 2018;74(10):2427-30. Durham ML, Suhayda R, Normand P, Jankiewicz A, Fogg L. Reducing medication administration errors in acute and critical care: Multifaceted pilot program targeting RN awareness and behaviors. J Nurs Adm. 2016;46(2):75-81. Gilmartin H, Goyal A, Hamati MC, Mann J, Saint S, Chopra V. Brief mindfulness practices for healthcare providers—A systematic literature review. Am J Med. 2017;130(10):1219.e1-17. Grissinger M. Safety requires a state of mindfulness. P T . 2017;42(11):662-3. Institute for Safe Medicine Practices. Independent double checks: Worth the effort if used judiciously and properly. June 6, 2019. ismp.org/resources/independent-double- checks-worth-effort-if-used-judiciously-and-properly Institute of Medicine. Preventing Medication Errors. Washington, DC: The National Academies Press;2007. KabatZinn J. Mindfulnessbased interventions in con- text: Past, present, and future. Clin Psychol Sci Pract. 2003;10(2):144-56. Klatt MD, Weinhold K, Taylor CA, Zuber K, Sieck CJ. A pragmatic introduction of mindfulness in a continuing education setting: Exploring personal experience, bridg- ing to professional practice. Explore. 2017;13(5):327-32. Sheridan C. The Mindful Nurse: Using the Power of Mindfulness and Compassion to Help You Thrive in Your Work. Lexington, KY: Rivertime Press; 2016. White L. Mindfulness in nursing: An evolutionary con- cept analysis. J Adv Nurs. 2014;70(2):282-94. As part of a medication safety pilot study conducted by Durham and colleagues, a mindfulness checklist was implemented for use with each medication administered to a patient. The checklist is located on the automatic dispensing cabinet in a “no interruption zone” for prepa- ration and on the mobile workstation for medication administration. The first step on the checklist has a red dot to signal the beginning of the preparation process: • STOP and focus on one breath. • While fully aware and present, review the medications against the electronic health record and decide whether they make sense for that patient right now; this is a mini medication safety check. • Prepare the medications, using single tasking. The next step is in the patient room: • STOP and focus on one breath. • Scan the ID attached to the patient and perform other system checks to verify the five rights of medication administration (right patient, right drug, right dose, right route, and right time). Ask questions such as, Is the dose correct based on weight and condition? Is the route ac- curate? Is time a consideration for the medication or condition? • Expect and intercept error. Adapt the checklist to key behaviors for the setting. For example, nurses in an ambulatory setting may use a flag system for medication reminders; pulling a flag prompts a mindful response. Mindfulness checklist July 2020 American Nurse Journal 27 ANA ON THE FRONTLINE NEWS FROM THE AMERICAN NURSES ASSOCIATION nn Conflict management for stronger teamsNext >