Reducing Near Miss Medication Events Using an Evidence-Based Approach

Near miss medication events are pervasive without patient harm, mostly because of coincidence. Dynamic clinical environments challenge nurse compliance with medication administration rights and proper use of electronic technology.

All nurses are educated in appropriate medication management, but our unit's barcoded medication administration scanning and electronic patient identification practices fell below the 97% benchmarks, representing hundreds of near miss medication events each month.

Transformative leadership guided frontline staff to identify gaps in care processes and determined root causes for unsanctioned medication administration practices using a FOCUS (Find-Organize-Clarify-Understand-Select)-PDSA (Plan-Do-Study-Act) methodology.

An interdisciplinary team committed to zero events of preventable harm overcame challenges to improve care delivery. Medication management scores exceeded organizational benchmarks, with sustainable gains over 2 years.

A rapid-cycle, evidence-based approach engaged staff to reduce near miss medication events. Workable solutions driven by transparent communication and interpersonal collaboration influenced positive safety behaviors.