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Reducing Nursing Related Medication Errors on Jade/Rainbow Unit
Lok, Sara Coyle, Rachel Supported by the Quality Improvement Team
Lok, Sara
Coyle, Rachel
Supported by the Quality Improvement Team
Abstract
Project Aim: Jade Unit’s weekly drug card audits were regularly showing medication errors conducted by the nursing team and prescribing staff. This was despite processes being put in place for extra checks of the drug cards to occur. On transferring, receiving or ordering medication there was a lot of paperwork involved that made checks difficult to understand. Our audits indicated there were regularly missing signatures, missing medication listed on the correct forms and incorrect administration of PRN medication between dosage times. The data has not changed although staff had been sent on additional training, supervision and extra checks built within the current process, therefore understanding what is causing the errors was important and a QI project was initiated.
Tools Used:
Driver diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf;
PDSA cycle - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf;
Process mapping - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-conventional-process-mapping.pdf;
Stakeholder feedback/ analysis - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-stakeholder-analysis.pdf;
SPC chart - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf.
Project Impact: This project surpassed its aim of 80% and achieved an overall reduction in nursing related medication errors of 86%.
MIDER Authors
Affiliations
Coventry and Warwickshire Partnership NHS Trust
Citations
Altmetric:
Date
2026-03
Type
Internal Poster
Subject
Collections
Citation
Lok, Sara; Coyle, Rachel. Reducing Nursing Related Medication Errors on Jade/Rainbow Unit. Coventry and Warwickshire Partnership NHS Trust, 2026.