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Updated: Feb 8, 2026
Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
Systemic analysis of medication administration omission errors in a tertiary-care hospital in Quebec
Thomas G Poder1, Serge Maltais2
1UETMIS and CRCHUS, CIUSSS de l'Estrie - CHUS, Canada.
Objective:
Medication administration omission errors (MAOEs) occur frequently in hospitals and can significantly affect patient health. An interdisciplinary committee was formed in summer 2012 to analyse incident/accident reports (AH-223-1 forms) of MAOEs for the 2011-2012 fiscal year in order to identify contributing factors and to propose preventive solutions. Special attention was paid to events with consequences for patients.
Method:
An aggregate data analysis involving four major steps was conducted: sampling, categorisation, identification of contributing factors, and seeking preventive solutions. One hundred omissions were randomly selected from the 889 reported for this period. All omissions categorised as having had consequences for patients were then added, making a final total of 145 omissions. The omissions were categorised using an Ishikawa diagram developed from an exploratory literature review and process mapping. Subsequent to failure modes, effects and criticality analysis, cause-and-effect diagrams were constructed with the main prioritised categories to differentiate the proximal causes from the root causes. Brainstorming was used to develop solutions, which were then prioritised with an impact/effort matrix.
Results:
This study identified 27 categories of MAOEs, of which the 7 most frequent and the most critical accounted for 79.3% of the reports. The event categories, in decreasing order of importance, were related to intravenous (IV) therapy (29.0%), failure in using the medication administration record (MAR; 23.4%), failure in creating/updating the MAR (10.3%), medications on the patient's bedside (7.6%), and three types of MAOEs related to transcribing prescriptions (9.0%).
Conclusion:
The interdisciplinary committee formulated 10 main recommendations related to these 7 categories, including 3 for IV therapy and 4 for failure in using or creating/updating the MAR.
Insights
Hospital medication administration omission errors (MAOEs) were analyzed to find causes and solutions. IV therapy and medication record issues were key factors, leading to 10 recommendations for improved patient safety.
Area of Science:
- Healthcare quality improvement
- Patient safety research
- Medication management systems
Background:
- Medication administration omission errors (MAOEs) are frequent in hospitals and pose significant risks to patient health.
- An interdisciplinary committee was established to investigate MAOEs, focusing on events with patient consequences.
- Analysis of incident reports from the 2011-2012 fiscal year aimed to identify contributing factors and develop preventive strategies.
Purpose of the Study:
- To analyze medication administration omission errors (MAOEs) reported in a hospital setting.
- To identify the primary contributing factors and root causes of MAOEs.
- To propose evidence-based preventive solutions to reduce MAOEs and enhance patient safety.
Main Methods:
- An aggregate data analysis of 145 medication administration omission errors (MAOEs) with patient consequences.
- Categorization of MAOEs using an Ishikawa diagram and failure modes, effects, and criticality analysis.
- Cause-and-effect diagrams and brainstorming sessions to identify root causes and develop prioritized solutions.
Main Results:
- Twenty-seven categories of MAOEs were identified, with the top 7 accounting for 79.3% of reports.
- Key error categories included intravenous (IV) therapy (29.0%), medication administration record (MAR) use (23.4%), MAR creation/updating (10.3%), and bedside medication storage (7.6%).
- Prescription transcription errors constituted 9.0% of the analyzed MAOEs.
Conclusions:
- Ten primary recommendations were formulated by the interdisciplinary committee, targeting the most critical MAOE categories.
- Specific recommendations focused on improving intravenous (IV) therapy administration and medication administration record (MAR) management.
- The study provides a framework for addressing systemic issues contributing to medication errors in hospital settings.
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