AuthorCapati, Mariana A.
AdvisorBullock, Lynn Marie Elizabeth
MetadataShow full item record
AbstractProblem & Purpose: In an ambulatory clinic located within Prince George’s County, Maryland, there is a pediatric clinic that has a low number of reporting medication safety events including near misses and actual events. A medication error report from 2021, showed only one medication administration error and zero near misses reported. Since “preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings,” it is important to increase medication safety event reporting to prevent future errors. This quality improvement initiative aims to increase medication safety event reporting in this clinic. Increasing near misses and error reporting will result in discovering and correcting underlying clinic or system problems that may exist and can prevent future medication errors from occurring. Methods: The QI project was implemented over a 15-week period in the fall of 2022. Two interventions, an educational session and an audit feedback tool, were used to increase the number of medication near-miss reports entered. Initial and ongoing education included a review of the reporting system and just culture, and staff were given a pre- and post-survey to assess their learning. The second intervention was the implementation of a standardized and validated tool, SBAR, which the manager used to provide timely feedback after a report was submitted. Results: 100% of staff completed the education. Post-education survey results showed there was an 83% increase in staff knowledge from baseline. At the end of the 15-week project, one medication error and one near-miss event were reported. This was an increase of 100% from the near-miss reporting baseline data. The audit feedback tool was used after the medication error was reported. Conclusions: Findings suggest that the teaching and audit feedback tool can be effective in increasing the medication near-miss reporting.
Rights/TermsAttribution-NonCommercial-NoDerivatives 4.0 International
Identifier to cite or link to this itemhttp://hdl.handle.net/10713/20811
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- Creative Commons
Except where otherwise noted, this item's license is described as Attribution-NonCommercial-NoDerivatives 4.0 International