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Authors

  1. Schmidt, Kaye MA, RN, CPON, NEA-BC
  2. Taylor, Amy BSN, RN
  3. Pearson, Anthony BSN, RN-BC

Abstract

Medication errors are a source of serious patient harm. A unique approach, Socio-Technical Probabilistic Risk Assessment, was used to analyze historical errors in this setting. The goal was to identify a minimal number of steps that would establish increased reliability and decrease errors if these steps were used every time. Three steps were identified that should be taken with every intravenous medication or fluid administration. Preliminary analysis revealed a 22% reduction in errors when using these 3 steps.