Implementing a safe and reliable process for medication administration

Clin Nurse Spec. 2012 May-Jun;26(3):169-76. doi: 10.1097/NUR.0b013e3182503fbe.


Purpose/objectives: The goal of this article was to outline a process change in medication administration using technology and led by clinical nurse specialists (CNSs) that has been successful and sustainable over time.

Background/rationale: The Institute of Medicine published a landmark report in September 1999 estimating that between 44 000 and 98 000 patients die each year because of medical errors. Errors are rarely the result of incompetent individuals using intentionally unsafe practices. Instead, errors usually result from poorly designed systems that do not prevent errors from occurring. Medication administration is an example of a multistep system that, because of its complexity, can be a challenge to accomplish safely and without error. It is estimated that errors from medication administration have led to 7000 deaths per year.

Description of the project/innovation: Using an electronic medication administration record with bar-code scanning for both patient and medication verification at the bedside is a technological methodology known to enhance medication administration safety. Many organizations have adopted these technologies, but not all have shown exceptional and sustained successes leading to a safer hospital experience for their patients. This article outlines the key steps that guided the CNSs from a small Magnet-designated New England hospital to improve medication administration safety. The project improvements were framed in the methods of reliability science.

Outcome: The article describes a practice change for nurses and pharmacists that resulted in sustained bedside medication scan rates of greater than 97% and medication error reduction from 2.89 errors per 10 000 doses before implementation of electronic medication administration record to a current rate of 1.48 errors per 10 000 doses.

Interpretation/conclusion: This improvement project demonstrates that CNSs can play a vital role in bringing electronic medication administration to the hospital environment. The CNS leaders established a network of relationships with experts in pharmacy, information technology, and patient safety to address the varied stakeholder interests.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Drug Therapy / methods
  • Drug Therapy / standards*
  • Humans
  • Medication Errors / prevention & control*
  • National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division
  • New England
  • Organizational Innovation
  • Safety Management*
  • United States