Reducing medication errors in an ambulatory medical center

Abstract

Background: Medication errors are a significant problem in ambulatory care, occurring at any stage, from prescribing to administration. Local Problem: Medication error rates due to interruptions were high on an ambulatory medical unit. Methods: A quality improvement design was used for the project. Interventions: A Safe Zone protocol was developed by nurses, certified nursing assistants, and unit secretaries. Implementation included clear medication preparation areas, administration checklists, and staff and patient education. Results: The number of distractions decreased by 20% over a 90-day period. Medication errors decreased from a rate of 0.97 events per 1000 doses administered to a rate of 0.20 after implementing the Safe Zone protocol. Conclusions: Due to its flexibility and adaptability, the Safe Zone protocol offers a template that can be replicated in environments needing to address similar issues.