Patient Safety Tip of the Week


November 3, 2009

Medication Safety: Frontline to the Rescue Again!



Two great studies have been recently completed, again demonstrating that frontline nursing staff still play the most important role in medication safety.


Linda Flynn, R.N., Ph. D presented in an INQRI webinar "Examining the Impact of Nursing Structures and Processes on Medication Errors" work that she and her colleagues had done on how nurses help prevent medication errors. Seizing on the IOM statistic that 50% of medication errors are caught before they impact the patient and 87% of those are caught by nurses, they sought to find out what goes through nurses’ minds to catch those errors. So they interviewed 50 nurses at 10 hospitals and found 7 key things that nurses do to intercept such errors:

1.      They independently evaluate and reconcile the MAR (medication administration record) with the original order, essentially performing an extra check.

2.      They do a “full assessment” of the patient (what does the patient look like overall at this time?).

3.      The question the rationale for the medication (what was it ordered for?).

4.      They discuss with the physician or make rounds with the physician.

5.      They educate the patient and family to enable them to become the last line of defense.

6.      They advocate with pharmacy for timeliness of medications.

7.      They ask the physician to rewrite the orders if there are handwriting legiblity issues or use of nonstandard abbreviations.


They then looked at barriers to accurate medication administration and found 2 that were most important. As you might anticipate, interruptions were one of those. They note that often the interruption is unnecessary (for example, the lab calls to see if the patient is back from radiology so they can come to draw blood samples) and the interrupting party could have obtained their information by other means. Second, the nursing/pharmacy interface was often poor. They provide, as an example, the scenario where pharmacy technicians daily switch out the medications in the patient’s “drawer”. If a patient is off the floor, pharmacy may take away a dose of a medication the patient was supposed to receive and the “new” drawer does not account for that dose. So nurses learn to hide the medication (actually physically hide the dose elsewhere so they can give it to the patient when he returns to the floor).


The second phase of their study evaluated factors in 14 hospitals that influence the medication administration process, looking at effects of nursing process, the practice environment, RN staffing, and technology. Of the 7 key things noted above, they found 4 that were statistically related to accurate medication administration: questioning the rationale for the medication, educating the patient/family to participate in safety, rewriting/clarifying orders, and independent reconciliation of the MAR and order. They then looked at various factors that predicted success of the medication administration process and found the following factors to be very favorable:

1.      A good overall practice environment (supportive manager, good staffing, good relationships with physicians, participation in decisions, and foundations for quality)

2.      RN hours per patient day

3.      Presence of computerized physician order entry (CPOE)


In the third phase, they did an analysis of the costs of medication errors at both a community hospital and a university hospital and concluded that the attributable cost of such errors averages almost $7000 per error.


In the Q&A session following the presentation in that webinar, some very good questions were asked. One good question was whether the methodology just included surveys and medication error reporting or if it utilized “naïve observation” (where an observor observes all the aspects of the process without actually knowing anything about the particular medication). This study did not utilize naïve observation. The questioner noted the importance of interruptions and noted that not all interruptions are external. Sometimes the nurse is multitasking and the interruption is self-imposed (eg. talking to someone who happens to walk by). Not surprisingly, that questioner was one of the investigators of the second study


That second study was done by UCSF’s Integrated Nursing Leadership Program (INLP) and involved 9 San Francisco Bay area hospitals. They used the “naïve observor” methodology and tied overall medication administration accuracy to compliance with 6 process steps identified as “best practices” by CALNOC (the California Nursing Outcomes Coalition):

1.      Compare medication to the medical record

2.      Keep medication labeled until administration

3.      Check two forms of patient identification

4.      Immediately record medication administration in the chart

5.      Explain the medication to the patient

6.      Minimize distractions and interruptions


Accuracy of medication administration (i.e. all steps done without error) was 83.8% at baseline and improved to 96% after 36 months, an overall 88% reduction of medication error rate. The numbers for adherence to the 6 best practice had almost identical numbers (improving from 80% at baseline to 96% afer 36 months).


Avoiding distractions and interruptions played an important role and low-tech solutions played a huge role (see Colliver article). Such solutions included wearing brightly colored vests or sashes when administering medication, or physically announcing at key points, or creating quiet zones. Such low-tech solutions often led to dramatic reductions in interruptions.


This study fits very nicely with the observations in our August 25, 2009 Patient Safety Tip of the Week “Interruptions, Distractions, Inattention…Oops!”, in which we discussed the analogy with the “sterile cockpit” in aviation and numerous types of interruptions and distractions and interventions to minimize them.


The two studies here provide graphic evidence of the importance of frontline workers as the last step in preventing medication errors from reaching the patient and causing harm. Though there is little doubt that high-tech solutions such as barcoding/bedside medication verification (BMV) have also led to dramatic reductions in medication errors, we have also seen as an unintended consequence an over-reliance on those high-tech solutions. We have all seen cases where the computer said its okay to administer that drug which was ordered in error because “you have the right patient, the right medication, the right dose, the right time” and the nurse trusts that computer system so much that the medication is administered even though he/she might have questions. So implementing the great low-tech principles and processes in these two studies can serve to improve the accuracy and safety of medication administration even above and beyond that seen with BMV. And both make us keenly aware that we must invest heavily not just in technology but also in our people and systems. Congratulations to both groups for great contributions to patient safety!





INQRI. Webinar "Examining the Impact of Nursing Structures and Processes on Medication Errors" Dr. Linda Flynn (link to both webinar and slides)



UCSF Program Achieves 88% Reduction in Medication Administration Error

Study Definitively Links Nursing “Best Practices” to Medication Administration Accuracy. Program Establishes Important Leadership Role for Front-Line Clinicians In Improving Healthcare Quality. Businesswire October 30, 2009 (study apparently to be published in the December 2009 issue of The Joint Commission Journal on Quality and Patient Safety)



Integrated Nurse Leadership Program - Clinical Outcomes Fact Sheet



Colliver V. Prescription for success: Don’t bother nurses. October 28, 2009



The CALNOC Medication Administration Accuracy Measure: Understanding Medication Administration Processes and Outcomes.




Update: The reference to the publication of the UCSF INLP study is below:


Kliger J, Blegen MA, Gootee D, O’Neil E. Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy.

Joint Commission Journal on Quality and Patient Safety 2009; 35(12): 604-612









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