Medication errors are a source of serious patient harm. A unique approach, Socio-Technical Probabilistic Risk Assessment, was used to analyze historical errors in this setting. The goal was to identify a minimal number of steps that would establish increased reliability and decrease errors if these steps were used every time. Three steps were identified that should be taken with every intravenous medication or fluid administration. Preliminary analysis revealed a 22% reduction in errors when using these 3 steps.
Center for Cancer & Blood Disorders (Ms Schmidt), Inpatient Medical-Surgical Units (Ms Taylor), and Nurse Informatics Liaison (Mr Pearson), Children's Health, Children's Medical Center, Dallas, Texas.
Correspondence: Kaye Schmidt, MA, RN, CPON, NEA-BC, Center for Cancer & Blood Disorders, B6-404, 1935 Medical District Dr, Children's Health, Children's Medical Center, Dallas, TX 75235 (Kaye.firstname.lastname@example.org).
Children's Health was engaged in a short-term contractual arrangement with Outcomes Engenuity, a private, for-profit consultancy, to evaluate a performance improvement concept to reduce medication errors.
The authors declare no conflicts of interest.
Accepted for publication: June 16, 2016
Published ahead of print: August 1, 2016