Reducing Medication Administration Errors in Acute and Critical Care: Multifaceted Pilot Program Targeting RN Awareness and Behaviors

Area of Science:

• Nursing Practice
• Patient Safety
• Human Factors Engineering

Background:

• Medication administration errors (MAEs) are frequent, preventable, and contribute to adverse drug events.
• MAEs often go unnoticed, intercepted, or reported, highlighting a critical gap in patient safety.
• The financial and patient-related costs of MAEs necessitate targeted safety interventions.

Purpose of the Study:

• To implement a pilot program aimed at increasing registered nurse (RN) recognition of medication error risks.
• To enhance RN behaviors associated with safe medication administration.
• To decrease the incidence of observed medication administration errors (MAEs).

Main Methods:

• Utilized process improvement methodologies and human factors principles to design the intervention.
• Employed an observational time-series study design to evaluate the program's impact.
• Focused on an interprofessional team approach to medication safety.

Main Results:

• Observed an increase in error interception practices during medication administration.
• Nurses reported adopting mindfulness strategies for improved situational awareness.
• Demonstrated more consistent performance of safe medication administration process behaviors.
• Found a reduced risk of medication administration errors (MAEs).
• Identified familiarity and complexity as factors influencing MAE outcomes.

Conclusions:

• The developed strategies effectively support safe medication administration.
• The pilot program shows potential for reducing medication errors.
• Findings are relevant for nurse leaders focused on enhancing medication safety.