Reducing near miss medication events using an evidence-based approach.

Janis Smith-Love

Study

Reducing near miss medication events using an evidence-based approach.

July 27, 2022

Smith-Love J. J Nurs Care Qual. 2022;37(4):327-333.

View more articles from the same authors.

Barcode medication administration (BCMA) is one approach to reducing near-miss medication safety events. Researchers used a FOCUS (find-organize-clarify-understand-select) PDSA (plan-do-study-act) methodology to help frontline nursing staff identify gaps in care processes and root causes contributing to poor compliance with barcode medication administration.

PubMed citation

Available at

Related Resources From the Same Author(s)

Reporting of hazards and near-misses in the ambulatory care setting.

October 19, 2011

Fall prevention with the Smart Socks System reduces hospital fall rates.

September 7, 2022

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

February 2, 2011

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.

April 4, 2012

Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis.

July 7, 2021

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

Influencing a culture of quality and safety through huddles.

November 9, 2022

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Patient Safety in Ambulatory Settings: Technical Brief.

December 16, 2015

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

Nurse burnout syndrome and work environment impact patient safety grade.

August 25, 2021

Inpatient Quality Indicators.

March 6, 2005

Impact of patient safety culture on missed nursing care and adverse patient events.

March 20, 2019

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

Resident physicians' advice seeking and error making: a social networks approach.

May 25, 2022

Long-term care nurses' experiences with patient safety incident management: a qualitative study.

August 4, 2021

A clinical pharmacist-led integrated approach for evaluation of medication errors among medical intensive care unit patients.

August 19, 2020

Usability and accessibility of publicly available patient safety databases.

June 1, 2022

Description and factors associated with missed nursing care in an acute care community hospital.

October 17, 2018

Design of an evidence-based "second victim" curriculum for nurse anesthetists.

June 1, 2016

Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.

December 8, 2021

Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care.

March 24, 2021

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events.

September 21, 2011

Building nursing intellectual capital for safe use of information technology: a systematic review.

February 9, 2011

Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.

May 12, 2021

Nurse's Achilles Heel: using big data to determine workload factors that impact near misses.

April 14, 2021

Safety competency: exploring the impact of environmental and personal factors on the nurse's ability to deliver safe care.

October 19, 2022

Nursing home patient safety culture perceptions among licensed practical nurses.

February 1, 2023

AHRQ EPC Program Grand Rounds - Making Healthcare Safer.

April 29, 2024 - April 29, 2024

Near miss research in the healthcare system: a scoping review.

May 25, 2022

Frequency of medication administration timing error in hospitals: a systematic review.

March 29, 2023

An evidence-based tool (PE for PS) for healthcare managers to assess patient engagement for patient safety in healthcare organizations.

May 26, 2021

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.

February 1, 2023

Association of adverse events in opioid addiction treatment with quality measure for continuity of pharmacotherapy.

February 16, 2022

Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm.

April 13, 2022

Patient perception of fall risk and fall risk screening scores.

March 15, 2023

Race differences in reported "near miss" patient safety events in health care system high reliability organizations.

December 15, 2021

Benefits of reporting and analyzing nursing students' near-miss medication incidents.

March 9, 2022

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

Development and validation of a brief culture-of-safety survey.

June 22, 2022

I'm sorry: laws that support apologies in health care.

February 5, 2020

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

Near-miss events detected using the emergency department trigger tool.

March 15, 2023

Towards the reduction of medication errors in orthopedics and spinal surgery: outcomes using a pharmacist-led approach.

January 16, 2008

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

November 30, 2022

Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design.

November 11, 2020

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

Improving infusion pump safety through usability testing.

May 31, 2017

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

Eliminating explicit and implicit biases in health care: evidence and research needs.

February 23, 2022

Registered nurses' judgments of the classification and risk level of patient care errors.

October 19, 2011

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.

May 25, 2022

The nurse's role in the causation of compensable injury.

October 12, 2011

Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate.

June 25, 2008

Perspectives on patient and family engagement with reduction in harm: the forgotten voice.

August 15, 2018

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety?

December 7, 2022

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

September 21, 2011

Implementation of patient safety structures and processes in the patient-centered medical home.

June 30, 2021

June 8, 2022

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward.

May 18, 2016

The COVID-19 pandemic: resilient organisational response to a low-chance, high-impact event.

July 15, 2020

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

Challenges and strategies for patient safety in primary care: a qualitative study.

September 28, 2022

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

Outcomes-based nurse staffing during times of crisis and beyond.

February 16, 2022

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Cost of adverse drug events related to potentially inappropriate medication use: a systematic review.

June 15, 2022

Development of a modified early warning score using the electronic medical record.

August 31, 2011

Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians.

January 8, 2020

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support.

May 18, 2022

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

Nurses' perceptions of causes of medication errors and barriers to reporting.

December 20, 2006

I-PASS handover system: a decade of evidence demands action.

May 12, 2021

Accuracy of pressure ulcer events in US nursing home ratings.

August 24, 2022

Quest for the ideal: a redesign of the medication use system.

January 31, 2007

A machine learning approach to reclassifying miscellaneous patient safety event reports.

July 29, 2020

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Patient safety in nursing practice.

July 20, 2005

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

COVID-19 pandemic: a time for collaboration and a unified global health front.

August 12, 2020

From HRO to HERO: making health equity a core system capability.

November 24, 2021

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic.

June 8, 2022

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis.

May 18, 2022

Accidental iatrogenic pneumothorax in hospitalized patients.

March 15, 2006

Communication about medical errors.

February 24, 2021

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

February 2, 2022

Allergy safety events in healthcare: development and application of a classification schema based on retrospective review.

June 15, 2022

The problem with…using stories as a source of evidence and learning.

March 9, 2022

Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.

April 27, 2022

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Related Resources

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units.

April 17, 2024

Challenge Competition: Impact of Patient Safety Tools.

December 12, 2023

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition.

October 25, 2023

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

August 9, 2023

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

August 2, 2023

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

June 28, 2023

The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap.

May 31, 2023

Medication safety event reporting: factors that contribute to safety events during times of organizational stress.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

April 19, 2023

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

April 19, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia.

March 8, 2023

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

February 15, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Medication errors: the year in review: January through December 2021.

January 11, 2023

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Journal Article

Study

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

November 16, 2022

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology.

October 5, 2022

Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events.

September 28, 2022

When medical error becomes personal, activism becomes painful.

September 28, 2022

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study.

September 7, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Emergency department adverse events detected using the emergency department trigger tool.

August 24, 2022

Health care quality and safety in a correctional system: creating goals and performance measures for improvement.

August 17, 2022

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

See More About The Topic

Hospitals

Quality and Safety Professionals

Nurse Care

Medication Safety

Medication Errors/Preventable Adverse Drug Events

Reducing near miss medication events using an evidence-based approach.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reducing near miss medication events using an evidence-based approach.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site