Using Direct Observation to Combat Medication Administration Errors

Using Direct Observation to Combat Medication Administration Errors


Name: Maria-Cristina Caruso

Rank: CPT

Presenter/Poster: Poster

Year: 2018


Description: Direct observation of the medication administration process provides a real-time snapshot of nursing practice to identify deviations from safe practice.

Objectives: The purpose of this project was to gather real-time data on the medication administration process and to improve nursing knowledge of safe practice as outlined in the facility's nurse practice policy.

Background: A 25-bed medical-surgical unit of a Military Medical Center reported an increased number of medication-related Patient Safety Reports (PSRs) despite implementing multiple safety checks throughout the past year. A literature review suggested using direct observation to identify deviations from safe practice. The unit had a medication administration audit tool for direct observation of peers, but the tool was outdated and no audits had been completed in the past year.

Method of Implementation: Nursing staff reviewed the medication administration policy to update the unit's audit tool. The updated tool consists of fifteen questions focused on the critical steps nursing staff must adhere to for safe medication administration. Each Registered Nurse and Licensed Practical Nurse was trained on the use of the new audit tool. Each nurse was expected to complete a total of eight audits during the period of 1 December 2017 to 31 January 2018.

Project findings: As of 27 January 2018, a total of 146 direct observation audits have been completed. From 1-15 December, major deviations from safe practice involved not verifying the time the medication was last removed from the medication dispensing system (5.9% of observations) and not verifying patient allergy information (17.6%). These deviations were present 16-31 December (5.7% for each) but improved greatly in all audits from 1 January until the present (zero instances of either). Other opportunities for improvement include reminding staff to use a second nurse to verify the dose of high-risk medications and ensuring the nurse educates the patient on new medications. Nursing staff are more knowledgeable regarding safe medication administration after using the audit tool for two months. Medication-related PSR data will continue to be reviewed post-implementation.

Implications for Military nursing: Direct observation on medication administration provides information regarding deviations from safe practice. It can also be used as a hands-on refresher for safe practices if the tool is in accordance with the facility’s nursing policy