Background: Medication administration errors (MAEs) occur in 3–8% of all non-intravenous drug doses given in UK hospitals; higher rates have been reported for intravenous drugs. Educational interventions are often advocated as one way of reducing these rates. However, group education sessions are often not practical. We developed internet-based educational modules on drug safety, and evaluated their effect on MAEs.
Methods: 11 modules were developed on different aspects of drug safety and delivered via commercially available software. All nursing staff on one ward were encouraged to participate. MAEs were identified using observation; the denominator used to calculate MAE rates was the number of opportunities for error. We aimed to observe 56 drug rounds before and after asking staff to complete the package.
Results: The 19 nurses who administered drugs on the study ward all agreed to participate. Of these, 12 (63%) nurses completed all 11 modules. Pre-education, 82 (6.9%) errors were identified in 1188 opportunities for error. Afterwards, 66 (5.0%) errors were identified in 1397 opportunities for error (95% confidence interval (CI) for the difference −3.8% to 0%). The MAE rate for non-intravenous drugs was 6.1% pre-education and 4.1% afterwards (95% CI for the difference −3.8% to −0.2%). Most errors with regard to intravenous doses were due to fast administration of bolus injections.
Conclusions: An interactive educational package focusing on patient safety was developed, with a high rate of uptake among nursing staff on the study ward. A reduction in non-intravenous MAEs was observed after the use of the package, but no significant change was seen in the overall error rate.
- MAEs, medication administration errors
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Funding: The Learning Clinic funded the study, but had no other involvement in collection, analysis or interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Competing interests: None declared.
An abstract describing a preliminary analysis of this work won the Pfizer Patient Safety Award for 2006, and was presented at the UK Clinical Pharmacy Association/Guild of Hospital Pharmacists Conference, Heathrow, UK, on 12 May 2006.
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