Quality Improvement:

Prevention of Medication
Errors
Kelly Cullinan, Abigail Jackson, Kristina Nealy & Jamie Steele
Quality Improvement Objective

After our clinical experiences and conductive research we have concluded

that barcode medication administration scanning systems are not always
easily accessible; therefore, they are not always utilized which puts patients
at higher risk for medication errors.
Our objective is to improve medication safety and reduce the incidence of
medication errors with the use of barcode medication administration
scanning systems.
Medication Errors

A medication error is any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in the
control of the health care professional, patient, or consumer 1 .
According to the FDA, at least one death per day and approximately 1.3
million injuries a year, are due to medication errors. This makes medication
errors the number one cause of sentinel events in hospitals 1.
Medication Errors Statistics

According to Cabilan, Hughes, and Shannon, medication errors occurred

during the following stages of medication administration 2:

During administration (62.7%)

Prescribing (28.6%)
Commonly during both stages (18.5%)
Aim Statement: Reduce the occurrence of medication administration errors
made in hospitals by increasing access to and use of barcode scanning
systems.
Root-Cause Analysis Team: Nurses, pharmacists, & computer technologists
Current approach:
Five rights of medication administration - Verifying the right patient, right medication, right
route, right dose and right time while independently force completing medication
administration.
Barcode Point Of Care systems are believed to be effective in preventing medication
administration errors but are currently implemented in only about 2% of U.S. hospitals 3.

A meta-analysis study conducted in 2015 reported a 57.5% reduction of

medication errors after fully implementing the barcode scanning system 4.
 Increase the number of WOWs (workstation on wheels) in units, barcode
point of care systems in each patient room.
Check the integrity of the wrist band and renew this band periodically 5
Print the barcode against a white background on transparent drug transfusion bags 5
Demonstration the skills of barcode scanning to nurses and inspect the function of scanners
periodically 5
Increase the number of access points for the wireless network 5
Demonstrate the procedure for adjusting the sound volume on the scanner 5
Medication Errors will decrease in percentage in units this program is
implemented in.
Will record data by having nurses self audit if utilizing barcode scanner
 Initiate a study to evaluate the incidence of medication errors within the
hospital before and after implementation
Audit patients electronic medication administration records (eMAR) to
ensure medications are being scanned, rather than force completed
Compare nurses self audit for barcode use with reviewing the patient's
eMAR
 Regularly utilize chart auditing to evaluate scanning compliance
Provide regular educational courses on barcode scanning
How to use barcode medication administration system
How to utilize modifying factors of the system for appropriate use
Require education with system updates
Provide rewards and incentives for using the barcode medication
administration system and attending educational seminars 5
Evaluate study for incidence of medication errors with implement of
barcode medication administration scanning
Implement improvements as necessary per research 6
 References
1. Center for Drug Evaluation and Research. (2016). Medication errors - Medication error reports. Retrieved from
https://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm
2. Cabilan, C., Hughes, J. A. and Shannon, C. (2017), The use of a contextual, modal and psychological
classification of medication errors in the emergency department: a retrospective descriptive study. Journal of
Clinical Nursing. doi: 10.1111/jocn.13760
3. Sakowski, J, , Leonard, T., Colburn, S., Michaelsen, B., Schiro, T., Schneider, J., Newman, J. (2005). Using a
Bar-Coded medication Administration System to Prevent Medication Errors. American Journal of Health-System
Pharmacy. Retrieved From
http://www.medscape.com/viewarticle/519719?trendmd-shared=1&src=trendmd_pilot.
4. Khammarnia, M., Kassani, A., & Eslahi, M. (2015). The efficacy of patients wristband bar-code on prevention
of medical errors: A meta-analysis study. Applied Clinical Informatics, 6(4), 716727. Doi:
10.4338/ACI-2015-06-R-0077
5. Yen, Y. T., Chang, S. F., Tsai K. L., Chen C. J., Liu, L. C., Fang, Y.C. (December 2015). A program to improve the
implementation rate for the barcode medication administration system. 62(6) 90-7. doi: 10.6224/JN62.6.90
6. Mims, E., Tucker, C., Carlson, R., Schneider, R., Bagby, J. (2009). Quality-monitoring program for
bar-code-assisted medication administration. American Journal of Health-System Pharmacy, 66, 1125-1131. doi:
http://dx.doi.org.ezproxy.hsc.usf.edu/10.2146/ajhp080172