Reducing Near Miss Medication Events Using an Evidence-Based Approach

Area of Science:

• Nursing Practice
• Patient Safety
• Healthcare Quality Improvement

Background:

• Near miss medication events are frequent, often due to environmental factors challenging adherence to medication administration rights.
• Unit-specific barcoded medication administration and electronic patient identification practices were below established benchmarks, indicating significant risks.

Purpose of the Study:

• To identify and address root causes of non-compliance with medication administration protocols.
• To implement and evaluate a quality improvement initiative to reduce near miss medication events.

Main Methods:

• A FOCUS-PDSA (Plan-Do-Study-Act) methodology was employed, guided by transformative leadership.
• An interdisciplinary team collaborated to analyze care processes and implement evidence-based solutions.

Main Results:

• Medication management scores surpassed organizational benchmarks.
• Sustainable improvements in care delivery and safety behaviors were observed over two years.

Conclusions:

• A rapid-cycle, evidence-based approach effectively engaged staff to reduce near miss events.
• Transparent communication and collaboration fostered positive safety behaviors and improved medication management.