Decreasing Medication Error by Increasing Family Involvement in Medication Administration

Decreasing Medication Error by Increasing Family Involvement in Medication Administration


Name: Lauren Cebulski

Rank: LTJG

Presenter/Poster: Poster

Year: 2017


Objective: Routine inpatient quality monitoring of patient safety event reports (PSR’s) on the inpatient pediatric unit (3 West) revealed the most frequent and serious errors were medication errors. A Quality Improvement project was designed based on Orem’s Self-Care Deficit Theory, which posits that nursing care supports patients and families when their own capacity for self-care is overwhelmed and specialized or advanced skills are needed. Educating the patient/family to provide nursing care, such as accurate administration of medications and treatments, is often a component of these interventions. The nursing leaders and staff developed this project to reduce variability in nursing practice, and reflect promising trends towards decreased inpatient medication errors.

Method: Medication errors are defined for this QI project as errors that resulted in a Patient Safety Report (PSR). While these may be prescribing, dispensing, or administration errors, this intervention is focused on medication administration, such as wrong medication, dose, route, or time (Per facility policy, more than 30 minutes before or after medications scheduled every 4 hours or more frequently, or more than 60 minutes before or after medications scheduled less frequently than every 4 hours).

The nursing leaders and staff developed a new process for orienting all patients/families to 3 West that focuses on family involvement in medication administration. All nursing staff was educated on the process using staff meetings, written scripts, and role paly.

Retrospective data were collected for 6 months prior to the start of the project on medication error rates (number of medication errors identified by PSR/number of inpatient days). Data were then collected for 12 months to account for seasonal variations in patient census and staffing changes. Charge nurses were tasked with twice daily audits to ensure staff compliance with the project and patient satisfaction was tracked through a survey given at the time of discharge.

Conclusions: Preliminary data* from this quality improvement project has showed a 59% decrease in the number of medication administration PSRs. Implementing a change in nursing practice to increase patient/family involvement in medication administration decreases medication error rates.

*Data collection will continue through the end of January 2017.