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  1. Donahue, Moreen DNP, RN, NEA-BC
  2. Brown, Joseph P. MAS, ATP
  3. Fitzpatrick, Joyce J. PhD, RN, FAAN


Medication administration is a major safety issue for patients and providers. The authors describe a commercial aviation-based system safety assessment conducted on the medication administration process for a community teaching hospital in the northeast United States. Processes on 2 medical units and 1 surgical unit were assessed. A sampling of qualitative outcomes is presented in a risk prioritization framework, along with practical recommendations predicated on the valuable lessons learned in commercial aviation.