title: Reducing Medication Administration Errors in Acute and Critical Care: Multifaceted Pilot Program Targeting RN Awareness and Behaviors.
abstract: OBJECTIVE
  The aim of this medication safety pilot program was to increase RN sensitivity to potential error risk, improve behaviors, and reduce observed medication administration errors (MAEs).
  
  
  BACKGROUND
  MAEs are common and preventable and may lead to adverse drug events, costing the patient and organization. MAEs are low visibility, rarely intercepted, and underreported.
  
  
  METHODS
  An interprofessional team used process improvement methodology to develop a human factors-based medication safety pilot program to address identified issues. An observational time-series design study monitored the effect of the program.
  
  
  RESULTS
  After the program, error interception practices during administration increased, and some nurses reported using a mindfulness strategy to gain situational awareness before administration. Process behaviors were performed more consistently, and the risk of MAE decreased. Familiarity and complexity were identified as additional variables affecting MAE outcome.
  
  
  CONCLUSIONS
  Strategies to support safe medication administration may reduce error and be of interest to nurse leaders.
authors.affiliation: Author Affiliations: Clinical Assistant Professor (Dr Durham), Health Systems Science, College of Nursing, University of Illinois at Chicago; Director (Dr Normand), Department of Preventative Medicine, Mindful Life Program; and Medication Safety Pharmacist (Dr Jankiewicz), Rush University Medical Center; Associate (Dr Suhayda), Provost Institutional Research, Assessment and Accreditation, and Director of Evaluation and Associate Professor, College of Nursing, Rush University; and Associate Professor (Dr Fogg), College of Nursing and Department of Psychology, Rush University, Chicago, Illinois.
authors.forename: Marianne L
authors.initials: ML
authors.lastname: Durham
authors.forename: Rosemarie
authors.initials: R
authors.lastname: Suhayda
authors.forename: Patricia
authors.initials: P
authors.lastname: Normand
authors.forename: Ann
authors.initials: A
authors.lastname: Jankiewicz
authors.forename: Louis
authors.initials: L
authors.lastname: Fogg
mesh_terms: D016638:Critical Illness / Q000451:nursing*; D006801:Humans; D007087:Illinois; D008508:Medication Errors / Q000517:prevention & control*; D009736:Nursing Process / Q000592:standards*; D017063:Outcome Assessment, Health Care; D010865:Pilot Projects; D017751:Safety Management