Opportunities to Reduce Medication Errors Term Paper

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The right route

Likewise, this clinician advises, "The administrator must give the medication via the right route. In preparing the medication, the triple check will identify the route to be given on the medication order."

The right time

Penultimately, double-checking the time is required: "The administrator will check the medication order to ensure that the medication is given at the right time. The prescriber will identify the times that the medication is to be given."

Proper documentation

Finally, clinicians administering medication are responsible for recording the client's status prior to the medication administration as well as the medication given, the time it was given, the dose given, and the route administered. In addition, "Then the administrator will follow up and record the client's response to the medication given."

Source: Adapted from Six Rights to Reducing Medication Errors, 2012


The project will consist of a series of custom-designed posters, 11" X 14" (released monthly) and newsletter entries (published weekly) focusing on each of the "six rights" (as described further below). The project leader will emphasize each of these "rights" by visiting clinical treatment areas and personally delivering the posters (which will be colorful and highlight the tenets of each of the rights). As appropriate, newsletter articles can amplify these rights and include additional information as needed.


The resources needed for this project are minimal as follows:

1. A series of six custom-designed posters highlighting each of the six rights and explaining its implications for healthcare providers. These posters would be designed by the tertiary healthcare facility's graphic aids department or by the project leader depending on expertise level.

2. Newsletter articles describing the "right of the month" and amplifying the information for healthcare providers.

Formative Evaluation

A "windshield" survey will be taken each week to determine how many clinical areas are posting the posters and casual conversations with healthcare providers will provide some indication of their reception. This casual evaluation will be followed-up with a more rigorous evaluation as described further below.

Summative Evaluation

A monthly comparison of medication errors by type and location will be conducted to determine the effectiveness, if any, of the Six Rights to Reducing Medication Errors project. The results of this comparison will be published in the tertiary facility's newsletter and included in relevant quality assurance reports that are already being disseminated throughout the facility. A final evaluation of the data will be conducted at the conclusion of the project to determine its overall effectiveness (if any).


A timeline reflecting the above is presented at Appendix a. In sum, the first month of the project will be spent designed posters, writing corresponding newsletter articles and announcing the initiative in available forums. A monthly evaluation of the project's progress will be followed by a final review upon completion of the project. If needed, the program could be readministered in its entirety as needed by focusing on those areas where the majority of medication errors are being made.


Bomba, D. & Land, T. (2006, August). The feasibility of implementing an electronic prescribing decision support system: A case study of an Australian public hospital. Australian Health

Review, (30)3, 3-5.

Evans, J. (2009, February). Prevalence, risk factors, consequences and strategies for reducing medication errors in Australian hospitals: A literature review. Contemporary Nurse: a Journal for the Australian Nursing Profession, 31(2), 19-20.

Mahmood, a., Chaudhury, H. & Gaumont, a. (2009, Winter). Environmental issues related to medication errors in long-term care: Lessons from the literature. HERD: Health

Environments Research & Design Journal, 2(2), 117-119.

Revere, L. & Black, K. (2003, November-December). Integrating Six Sigma with Total Quality

Management: A case example for measuring medication errors. Journal of Healthcare

Management, 48(6), 37-39.

The six rights to reducing medication errors. (2012). Medication Administration: The 6 R's.

Retrieved from http://www.scribd.com/doc/6418403/Medication-Administration-the-6-

Wine, J. & Khanfar, N.M. (2008, September-October). Sunny View Memorial Hospital: A day in the life of a busy hospital pharmacy -- medication errors, managers, and missing medications, Oh my! Journal of the International Academy for Case Studies, 14(5), 119-

Appendix a

Proposed Timeline for Project


TIME (MONTHS) -- 2012-2013














Poster design, article development




Poster distribution and article publications



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