MSN support page for analyzing a medication administration near miss, stakeholder implications, root-cause factors, and a QI initiative to prevent recurrence.
This assessment requires a 5–7 page analysis of an adverse event or near miss from nursing experience and a proposed quality improvement initiative to prevent recurrence.
Safety is a key priority of modern day nursing. Systematic progress in use of electronic health technologies and evolving, multi-professional educational standards and protocols notwithstanding, medication errors remain a significant and potentially harmful hazard to patient health. According to Rodrigues et al. 2024, medical errors are acknowledged as a preventable cause of death in the United States, whereby an estimated 400,000 people in the country are injured as a result of preventable medical errors every year. Medications are a major and preventable subset of adverse events in this environment, called medication administration errors (MAE). This paper provides a comprehensive analysis of a medical-surgical unit (MSU) near-miss medication administration error (MAE) was performed and discusses the medical-surgical unit near miss MAE event with the application of an RCA tool and explores quality improvement (QI) technologies and strategies across healthcare institutions that were adopted at the medical-surgical unit to prevent occurrences, and discusses a structured QI initiative for the medical-surgical unit that was implemented.
The near miss event being studied took place on a busy medical-surgical floor on a night shift. A registered nurse (RN) had no access to the patient logs because he was too ill to document. A patient shot out of the intensive care unit (ICU) earlier that day, was a post-operative patient, and would have needed to have his access to patient logs, but was too ill to record. The receiving nurse was not conducting a full medication check when handing off. Due to documentation delay, the patient's order for metoprolol to be held because of a systolic blood pressure of 88 mmHg had not been well documented and communicated in the electronic medication administration record (eMAR). When the nurse tried to administer the medicine to the patient, she scanned the wristband on the patient and entered it into the BCMA because the scan ID was not showing a contraindication, since the hold was not in place. A final assessment was done by the nurse before giving the medicine and the blood pressure was documented as 86/58 mmHg. The nurse refused the Medication, reported this to the charge nurse and the physician notified straight away. No harm occurred, however, as the incident was formally reported as a ‘near miss'.
The near-miss medication event had significant implications for many stakeholders. The patient's risk of potentially severe complications was exacerbated, and the accident led to a loss of patient and family trust in the healthcare team. The nurse(s) who made the error might have experienced moral distress because there were contributory factors in the system that caused the error. This is the “second victim” effect described by Harrison and colleagues (2022), whereby clinicians experience the impact of negative psychology with regards to errors that occur and/or come close to occurring and also near misses. This has also led to the recognition of certain weaknesses within the communication and documentation of the organization including team cooperation, maintaining accurate documentation and safe practices.
Root Cause Analysis (RCA) is a systematic technique to gain insight into systemic causes of adverse events, near miss events. An RCA analysis of the evidence from this near miss revealed that there was a series of failures that led to this near miss occurring, perhaps the result of an act of carelessness. This event was a result of the medical management and not necessarily the patient's surgical status and/or was related to the documentation and communication protocol utilized in connection with a medication hold.
The near-miss medication incident was attributed to many factors. Communication of med-surg non-compliance with the transfer from the ICU which led to a gap in transferring patient meds/hemodynamic instability at medical-surgical unit. Communication problems during the transition of care are among the Joint Commission's National Patient Safety Goals, which list them as one of the largest causes of medication errors. Secondly, due to the delay in updating the eMAR entering nurse had inaccurate medication information. Third, BCMA participants supported the checks on patient information and drug verification, but lacked the facility to document findings about medication “hold” which led to a false sense of security. Finally, the night shift working was associated with fewer opportunities for careful medication review. The factors described in this incident relate to factors that Coelho et al. (2024) identified as contributing to medication-errors: workloads of nurses, ineffective communication and supervision between the professions.
The near miss could have been avoided. Several other factors could have broken the chain of error, including having a structured handoff tool like SBAR (Situation, Background, Assessment, Recommendation), a dual-nurse medication reconciliation before transferring the patient, having the patient's vital signs checked and documented before handing them the cardiovascular medication, and/or having the eMAR (electronic medication administration record) synchronized between units in real time. Systemic: No single person is responsible for the failure, there are communication failures and organisational failures that all combined into the near miss.
There are several technologies and practices of QI which have obvious application in the prevention of this type of near miss. BCMA systems represent some of the most successful technological interventions used to lower MAEs, and are evident-based in nature. Several studies were conducted that found that when using the technology of the BCMA along with the use of electronic Medication Administration Records (eMAR), errors in medication administration decreased by up to 40–70% (as cited in Westbrook et al., 2024). However, research that has identified the limitations that accompany the use of BCMA is important too. The mixed methods study published in BMC Health Services Research revealed that many facilities across the country continue to have lower than 30% rates of BCMA adoption and often their workflows are problematic or there are nurse workarounds such as bypassing wristband scanning (Grailey et al, 2023). It was an example of such a ‘near miss' as outlined in the analysis, with the implementation of the BCMA, but where the documentation workflow was still not complete.
Other institutions have several different safety measures in place to ensure it does not happen again. The Veterans Health Administration (VHA) implemented transitional care (ToC) pharmacy-driven medication reconciliation (MR) with the result that medication mismatch (MM) rates at ToC have dropped significantly since the implementation. Medication mismatch is no longer a problem at the 22 medication reconciliation programs established at the transition of care (ToC), as these programs have been driven by the Pharmacy at the VHA. Different hospitals have instituted interprofessional hand off processes, including nursing and the pharmacy co-verification of medication on inventory before the patient is shifted to another unit; this is one of the Magnet hospitals' practices. Real time clinical decision support (CDS) can be embedded within the electronic health records (EHRs) system to alert nurses to assess the patient before administering a medication if the range for vital signs metrics is outside of the “safe” zone for the scheduled medication. A systems approach to medication safety drawing on the overlap concept recommended by the Guentschnig et al. (2025), but further developing it, and incorporating human factors engineering at the lowest end and collaboration amongst pharmacists on the unit and automated clinical alerts at the top in a pyramid of medication safety.
Relevant measures used as indicators of performance in data collected from institution records that measure MAEs tend to include MAE rates for 1,000 doses of medication administered, the grade of the event (near miss, serious harm), and MAE's that result in readmission. Patient satisfaction ratings (including the HCAHPS survey score) may indicate a lack of trust in communication with the nursing community when patients are made aware of drug mistakes. Medication Errors at Care Transitions has consistently appeared on the top five list of trends in patient safety events nationwide, as determined by data from the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network. Consequently, a comparison of time on the documentation lags related to handoffs, as reflected in data from the internal unit, with best-practice benchmarks emphasizes the need for a formal QI opportunity.
The initiative is framed using the Plan-Do-Study-Act (PDSA) cycle, a widely validated QI model endorsed by the Institute for Healthcare Improvement (IHI).
Planning involves creating a multidisciplinary team: floor nurses, charge nurses, ICU nurses, attending physicians, clinical pharmacists, and unit managers. This team will lastly perform an official comparative analysis of existing handoff procedures, eMAR documentation timelines and the level of compliance with BCMA. The baseline data will be collected for 4 weeks with the incidents of the MAE, near-misses and eMAR documentation lag time from ICU to the medical-surgical room for all transfers. The main aim should be to cut medication discrepancies by half in 6 months following implementation in relation to transferring patients as reported by previously published Benchmarks from the Medication Without Harm challenge by the World Health Organization.
Three evidence-based interventions will all be put in place concurrently. There will be an SBAR structured handoff checklist adopted for all transfers from the ICU to the floor with required fields for held medication(s) and medical reasoning for any held medication(s). Second, real-time eMAR synchronisation will be continued via IT Partnership and medication hold orders that are entered in the ICU will be instantly picked up in the receiving unit before the patient is transported. Third, nurses will have targeted training on cardiovascular medication safety which will focus on the need to evaluate relevant vital signs at an immediate time before risk of medications and documenting this on the eMAR with an affirmative assessment. Patients of any type that are transferred will have prospective medication reconciliation completed within 1 hour of transfer to the floor by the pharmacist.
A unit provided safety dashboard will be used to track outcomes on a monthly basis. KPIs for the successful implementation of SBAR medication documentation for transfers include: (1) percentage of SBAR documentation on medication transfer checklists; (2) eMAR documentation lag time (less than 15 minutes from verbal order to eMAR entry); (3) 95% compliance rate of scanning BCMA; (4) number of medication discrepancies or medication near-miss reports; and (5) staff satisfaction levels with the new protocol (assessed through post-implementation survey). Patient satisfaction scores will additionally be monitored with regards to nursing communication. The importance of sustained improvement is highlighted by Rodziewicz et al. (2024) who note that sustained improvement can only be achieved with continued measurement, clear reporting of the unit's results to the unit and units' leadership, and a leadership commitment to improvement. Rodziewicz et al. (2024) state that these principles will be built into the monthly safety huddles on the unit.
Results will be followed up with the multidisciplinary team at three months. When metrics have improved, the protocol will be adopted and shared across units in the facility. Consistent review and debriefing of the team will ensure gaps will be identified and interventions adjusted if there are any. The MSTC program will be turned into the patient protection plan and submitted for institution's adoption and recurrent resource allocation.
The near-miss medication administration event serves to illustrate that patient safety failures frequently occur across more than a single point of failure within a system. The incident may have been caused by lack of communication, delayed documentation and technology constraints. Standardized handoffs, medication records in real-time medication system, effective barcode medication administration, and a pharmacist-led medication record system can minimize similar risks. Overall, the proposed MSTC quality improvement initiative is a viable strategy for enhancing medication safety and improving patient care. Finally, promoting teamwork, accountability, and constant quality improvement needs to be part of the culture so that it can be demonstrated and promote the delivery of safe, high-quality nursing care.
Coelho, F., Furtado, L., Mendonça, N., Soares, H., Duarte, H., Costeira, C., Santos, C. and Pereira Sousa, J. (2024). Predisposing Factors to Medication Errors by Nurses and Prevention Strategies: A Scoping Review of Recent Literature. Nursing Reports, [online] 14(3), pp.1553–1569. doi:https://doi.org/10.3390/nursrep14030117
Grailey, K., Hussain, R., Wylleman, E., Ezzat, A., Huf, S. and Franklin, B.D. (2023). Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. a mixed methods study. BioMed Central Nursing, [online] 22(1), pp.1–12. doi:https://doi.org/10.1186/s12912-023-01382-x.
Guntschnig, S., Barbosa, R., Jenzer, H., Greening, M., Hayde, J., Heery, H., Iglesias Serrano, M. C., Lajtmanová, K., Rossin, E., Tentova-Peceva, S., Kohl, S., & Mulac, A. (2025). Tackling medication errors: How a systems approach improves patient safety. European Journal of Hospital Pharmacy. https://doi.org/10.1136/ejhpharm-2025-004533
Harrison, R., Johnson, J., McMullan, R. D., Pervaz-Iqbal, M., Chitkara, U., Mears, S., Shapiro, J., & Lawton, R. (2022). Toward constructive change after making a medical error: Recovery from situations of error theory as a psychosocial model for clinician recovery. Journal of Patient Safety, 18(6), 587–604. https://doi.org/10.1097/PTS.0000000000001038
Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
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