Trending Medication Errors: Improving Patient Safety through Quick Wins

Trending Medication Errors: Improving Patient Safety through Quick Wins


Name: Kimberly Barcus

Rank: MAJ

Presenter/Poster: Both

Year: 2018


Objective: The objective of this project was to utilize “quick win” methodology to decrease medication errors on an Inpatient Surgical Unit at Fort Belvoir Community Hospital.

Background: 68% of all the PSRs submitted for the Inpatient Surgical Unit were medication errors. The selected interventions sought to achieve “quick wins,” in that they were simple to put into practice, were targeted to produce results, and required minimal resources. Of the 4 “quick-wins” implemented from March – July 2016, 3 required no funding, 2 required only internal coordination, and 3 required less than one month to implement.

Methodology: PSR trending was conducted from January to October of 2016 by the unit Clinical Nurse Specialist. Four recurring problems were identified and a targeted intervention selected for each.
1. Glass-vialed intravenous medications were not fully infusing through the infusion pump as programmed. The nursing staff received training on the technical aspects of glass vial medication administration.
2. Intravenous piggyback medications requiring reconstitution were being administered without reconstituting. The pharmacy began placing “activate before infusing” labels on all medications requiring reconstitution.
3. Medications with a limited number of doses ordered were continued after reaching the specified limit. The nurses modified their electronic documentation to include the dose number given.
4. Ibuprofen and ketorolac were administered concurrently within the OB-GYN population. The verbiage in the standard post-operative order set was clarified.

Findings: Implementation occurred during March, April, June, and July, 2016. Early success with the intervention for glass vial and piggyback medications in March and April allowed us to focus on newly emerging error trends and move on to implement interventions in June and July for the limited dose and consecutive administration medications. During the 3-6 months following intervention, the targeted errors were either not repeated or only repeated once.

Implications for military nursing: Not every problem requires a formal project, policy, or working group to address. Some error trends can be effectively addressed with solutions that require minimal resources, coordination, and time. Quick win interventions are particularly applicable to the military community because of the increased organizational turnover. Lengthy project timelines are not always the most feasible or effective solution.