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The Challenge

Leadership at a long-term care (LTC) facility that offered skilled nursing and an Alzheimer’s unit recognized the need to reduce medication errors by getting to the root cause(s). Leadership wanted to assess:

  • Medication administration
  • Medication error reporting, investigation, analysis, and dissemination of “lessons learned”
  • Training relative to medication administration

INsight assessment services are available as web-based surveys only, on–site surveys only, or a combination of the two. After ECRI Institute analysts discussed the client’s challenges, scope of concern, desired outcomes, and goals for conducting a medication safety assessment, an on-site consultation was conducted.

The Solution

ECRI Institute identified significant safety opportunities in key areas of the facility's medication administration process. Based on the results, our long-term care experts then led an educational session on identification, notification, investigation, and systems analysis. This session was presented as part of the effort to reduce errors and facilitate a culture of safety—all designed to help make staff feel safe in reporting medication errors so that lessons learned could be identified and shared with appropriate staff.

The Result

As a result of the assessment, the LTC leadership team implemented major improvements in the facility’s medication administration processes. They now discuss issues and errors in terms of process and system changes that might be needed rather than focusing on and blaming individual staff. LTC leadership also created a multi-disciplinary, streamlined approach to policy and procedure review.

A pilot project allowing for a quiet zone as part of the medication administration process was initiated. Some simple changes, such as including “Do Not Disturb” signs on medication carts and assigning charge nurses to manage phone calls and patient calls during medication administration were implemented.

The organization also revised its medication event form to include a taxonomy that captures resident harm scores for each medication error reported, a collection of contributing factors information for each reported event, and any resident follow-up needed or taken. Based on ECRI Institute's recommendations, the facility formed a quality improvement team to discuss resident safety issues and performance improvement efforts. A standing item of this team meeting is a review of reported events and a dissemination of medication safety updates that include lessons learned.


Learn more about INsight Assessment services.