A Quality Improvement Project to Reduce Medication Errors in the Assisted Living
Desire’ N. Patrick
Abstract
According to the National Coordinating Council for
Medication Error Reporting and Prevention, a medication
error is defined as “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” (National coordinating
council for medication error reporting and prevention, 2020).
Medication errors are unfortunately common in assisted
living facilities. Some of the contributing factors of
medication errors include no physician on site, complex
medication regimens, utilizing off site pharmacies, and
inexperienced staff administering medications. By developing
and implementing effective polices, procedures, and process,
medication errors can be reduced significantly.
Introduction
In an assisted living facility setting, medication errors are
common and often go unreported. More than 80% of the
residents rely on staff for medication administration and
management. Since January 2020, several
medication errors have been reported at a Bon Secours ALF.
Medication errors are serious safety events that could have a
negative impact not only on the resident
but also on the facility. Medication safety remains a top
priority for many agencies such as Agency for
Health Care Administration (AHCA) and the Center for
Medicare and Medicaid. These agencies govern
the rules for all ALF settings.
After observing several medication passes and reviewing
policies, procedures, and processes, it was determined that a
quality improvement project for a more efficient and
structured system was needed to attempt to reduce
medication errors and promote resident and staff safety.
Facility
Bon Secours Memorial College of Nursing
Materials and Methods
For this QI project, multiple interventions were needed for
implemented to ensure success in the reduction of medication
errors.
To start, observation was needed to determine where problem
areas occurred. Five medication passes on both dayshift and
evening shift were performed on medication technicians and
nurses every shift for one week. A review of the previously
reported medication errors since January 1st determined common
causes for errors.
Results
The results showed a significant decrease in medication errors
from pre to post quality improvement project.
50 Audits were performed weekly (10 daily in two divided
shifts) 25 were nurse audits and 25 were medication technician
audits.
200 audits were performed monthly.
In total, 800 audits were conducted from August – November .
• The total number of errors reported January 2020- April
2020 were 25.
• The total number or errors reported post QI August 2020-
November 2020 were 5.
# of Medication
Errors
Medication Errors Pre QI (January- 25
April)
Medication Errors Post QI (August-
5
November )
Conclusion
After observations were made, medication cart checkbooks were As illustrated in the results, the medication errors
implemented on every medication cart to ensure proper adherence decreased significantly after the QI project. Pre QI project
to following all medication administration polices and procedures. there were 25 medication errors in a four-month span
These medication cart checkbooks were audited weekly. (January-April) compared to five medication errors post
After a few weeks of the medication cart checkbooks, five QI project in a four-month span (August-November).
observations were made every shift for a week to determine if These results are the equivalent of pre-QI error rate of
medication errors decreased. 6.25 med errors per month, compared to post QI error
Safecare reports and observations were compared pre and post rate of 1.25 medication error per month.
project.
Total Medication Errors (Aug-Dec) References
2 2
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• The last error occurred in the second week of September
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Acknowledgements
Thank you to my mentor and the Assisted Living Facility
to allow me to implement these policies and procedures
as well as assist in the promotion of patient and staff
safety.