The aim of this medication safety pilot program was to increase RN sensitivity to potential error risk, improve behaviors, and reduce observed medication administration errors (MAEs).
MAEs are common and preventable and may lead to adverse drug events, costing the patient and organization. MAEs are low visibility, rarely intercepted, and underreported.
An interprofessional team used process improvement methodology to develop a human factors–based medication safety pilot program to address identified issues. An observational time-series design study monitored the effect of the program.
After the program, error interception practices during administration increased, and some nurses reported using a mindfulness strategy to gain situational awareness before administration. Process behaviors were performed more consistently, and the risk of MAE decreased. Familiarity and complexity were identified as additional variables affecting MAE outcome.
Strategies to support safe medication administration may reduce error and be of interest to nurse leaders.