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Best Practices to Decrease Infusion-Associated Medication Errors

Wolf, Zane Robinson PhD, RN, CNE, FAAN; Hughes, Ronda G. PhD, MHS, RN, CLNC, FAAN

doi: 10.1097/NAN.0000000000000329

Infusion-associated medication errors have the potential to cause the greatest patient harm. A 21-year review of errors and near-miss reports from a national medication error-reporting program found that infusion-associated medication errors resulted in the identification of numerous best practices that support patient safety. A content analysis revealed that most errors involved improper dosage, mistaken drug choice, knowledge-based mistakes, skill-based slips, and memory lapses. The multifaceted nature of administering medications via infusions was highlighted. Opportunities for improvements include best practices such as developing learning cultures and reinforcing the independent double-check process on medications. Staff will likely benefit from education on specific medications, prescription details, and smart pump technology.

La Salle University School of Nursing and Health Sciences, Philadelphia, Pennsylvania (Dr Wolf); and University of South Carolina, Columbia, South Carolina (Dr Hughes).

Zane Robinson Wolf, PhD, RN, CNE, FAAN, is dean emerita and professor at the nursing program at La Salle University School of Nursing and Health Sciences. Dr Wolf has investigated medication errors for more than 25 years. She also studies nursing rituals, nurse caring, patient satisfaction, and educational topics.

Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN, is director of the Center for Nursing Leadership and an associate professor at the University of South Carolina. Dr Hughes conducts research on outcomes studies and health systems and health care administration topics using large data sets. She has published in numerous journals and is also the editor of a book on patient safety and quality.

Corresponding Author: Zane Robinson Wolf, PhD, RN, CNE, FAAN, School of Nursing and Health Sciences, La Salle University, St. Benilde Tower 4015, 1900 West Olney Avenue, Philadelphia, PA 19141 (

The authors of this article have no conflicts of interest to disclose.

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