1. Force, Mary VanOyen BSN, RN
  2. Deering, Linda MSN, RN
  3. Hubbe, John PharmD, JD
  4. Andersen, Marcy RHIA
  5. Hagemann, Barbara RPh
  6. Cooper-Hahn, Michelle BA
  7. Peters, William MS


A major concern for patient safety in hospitals is accurate medication administration. To improve the medication administration process, nurses and pharmacists must report system problems. Although staff supported the concept of medication error reporting, they did not report errors. Inherent fear of retribution, punitive actions, and professional humiliation prevented self-reporting of medication errors. Our hospital's quality improvement department developed, implemented, and evaluated a program called LifeSavers. Its purpose was to build a nonpunitive culture and to increase medication error reporting by staff. In one year, the LifeSavers program increased medication error disclosures from 14 to 72 reports per month. The successful development of a nonblame culture of medication error reporting led to identified sources of problems and improvement of the medication administration system.