Reducing Medication Errors through Multi-Disciplinary Collaboration: A Quality Improvement initiative

Document Type : Brief Report


1 Pediatric Specialist Registrar, Health Education and Improvement Wales, UK.

2 Nurse Educator, Department of Nursing, Morriston Hospital, Swansea, UK.

3 Lead Pediatric Pharmacist, Morriston Hospital, Swansea, UK.

4 Consultant Paediatrician, Morriston Hospital, Swansea, UK.


Prescribing and medication administration errors are common themes in Pediatrics. There is growing international evidence that the regular occurrence of such errors carries a high potential for unintended harm to patients. Within our Trust, a high percentage of reported pediatric incidents relate to medication errors. The most-commonly reported themes were incorrect dosing and omission of regular medication. The aim of our project was to reduce medication errors by at least 10%.
 Materials and Methods:
To achieve our aim, we devised a structured educational program was devised by a tripartite alliance (Nursing, Medicine, Pharmacology) and rolled out to nursing staff and medical trainees. An initial prospective audit was undertaken, followed by two PDSA (Plan-Do-Study-Act) cycles.
Following the intervention, the percentage of medication errors decreased from 89.3% to 12.1%, with a comparative 51.3% decrease in significant errors and a complete elimination of serious/potentially lethal errors.
In view of our results, we hope that tripartite alliances may be used as a model for inter-professional collaboration across healthcare systems.


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