Theory Informed Audit and Feedback to Decrease Medication Administration Errors

Medication administration errors remain a serious and preventable cause of morbidity and mortality in health care. Technology at the point of care is often bypassed in the medication administration process despite the intention to prevent adverse drug events through the addition of a layer of cross-checks and alerts. The purpose of this project was to understand if human behavior could be influenced using effective audit and feedback, data transparency, and communication tactics to decrease administration-related errors, such as wrong patient, wrong medication, wrong dose, and adverse drug events, with the use of barcode medication administration (BCMA) in the emergency department. This evidence-based practice (EBP) project, utilizing a quasi-experimental approach to collect and analyze data, focused on communication of medication error rates and BCMA compliance rates for medication administered in the pilot unit before, during, and after, the leadership team and project leader used theory-informed feedback interventions. The result was a decrease in the number and severity of events categorized as medication administration errors. The BCMA compliance rate in the pilot unit rose during the intervention period to exceed the organizational goal of 96%.