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P32 - Sustaining the Intervention for a Journey to Zero Medication Administration Error

Purpose: The purpose of this initiative was to increase clinical staff awareness on the potential risk of medication administration error (MAE), to improve staff’ behaviors, and to reduce MAEs.

Description: MAEs, although, common and preventable, may lead to adverse drug events, costing the patient and the organization. It is reported approximately that four in 10 patients are harmed in primary and outpatient health care settings, with up to 80 percent of those MAEs being preventable (Finnegan, 2020). Similarly, at Community Healthcare Network, MAEs – although common – could have been prevented.
To help prevent the MAE occurrences at CHN, an interdisciplinary team of nurse leaders, nursing front-line staff, and clinicians implemented a multifaceted process improvement approach. This multifaceted process improvement comprised the creation of electronic medication for single and multi-dose vaccination vials, the implementation of two-staff verification for medication administration, the weekly audit of medication expiration, the random audit of the medication management process by central leadership, a fishbone focused on the causes of the medication errors, and staff training and education. The effectiveness of this approach is continuously being monitored.

Evaluation/outcome: A month into the implementation process, which was rolled out in February 2020, a remarkable MAE reduction of 40% was noted when comparing the months of March 2019 and March 2020. Additionally, when comparing the time period of March through October 2019 and 2020, a reduction of 33 percent in MAE was noticed.

Although systematic reviews stipulate that there is not enough data to support the impact of two-staff verification in preventing medication errors, this pilot study reveals that multifaceted strategies to support safe medication administration may reduce medication administration errors.

1. Finnergan, J. (2020, January 28). 4 in 10 patients harmed by medical errors in primary and outpatient settings. Fierce Healthcare. https://www.fiercehealthcare.com/practices/medical-errors-globally-as-many-as-4-10-patients-harmed-primary-and-outpatient-settings
2. Koyama, A. K., Maddox, C.-S. S., Bucknall, T., & Westbrook, J. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ, 29, 595-603. http://dx.doi.org/10.1136/bmjqs-2019-009552

Learning Objective:

  • After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.


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