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  1. Smith-Love, Janis DNP, APRN, ACNP-BC, CCRN, CHFN


Background: Near miss medication events are pervasive without patient harm, mostly because of coincidence. Dynamic clinical environments challenge nurse compliance with medication administration rights and proper use of electronic technology.


Problem: All nurses are educated in appropriate medication management, but our unit's barcoded medication administration scanning and electronic patient identification practices fell below the 97% benchmarks, representing hundreds of near miss medication events each month.


Approach: Transformative leadership guided frontline staff to identify gaps in care processes and determined root causes for unsanctioned medication administration practices using a FOCUS (Find-Organize-Clarify-Understand-Select)-PDSA (Plan-Do-Study-Act) methodology.


Outcomes: An interdisciplinary team committed to zero events of preventable harm overcame challenges to improve care delivery. Medication management scores exceeded organizational benchmarks, with sustainable gains over 2 years.


Conclusions: A rapid-cycle, evidence-based approach engaged staff to reduce near miss medication events. Workable solutions driven by transparent communication and interpersonal collaboration influenced positive safety behaviors.