Journal Article

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

Kliger J, Blegen MA, Gootee D, et al. Joint Commission journal on quality and patient safety. 2009;35:604-12.

A significant proportion of medication errors occur at the administration stage, and therefore are unlikely to be prevented by solutions such as computerized provider order entry, which primarily target the prescribing stage. To address this problem, seven hospitals participated in a quality improvement collaborative to engage frontline nurses in addressing medication administration errors. Through a rapid-cycle improvement process, each hospital developed methods to implement and monitor six specific safety processes. For example, one focus was on minimizing interruptions during medication administration, as frequent interruptions have been linked to errors in prior research. The project resulted in a significant reduction in administration errors across all six hospitals included in the analysis.