UCSF Program Achieves Over 56% Reduction In Medication Administration Error

A demonstration program at UCSF reported a 56.8% reduction in medication administration errors - increasing the administration accuracy rate at participating hospitals to 93%. These gains were achieved through adherence to a set of six "best practice" procedures for medication administration identified by CalNOC (the California Nursing Outcomes Coalition). The study also reported a reduction in procedural errors of 78.5% - increasing adherence to these "best practice" procedures to 95.6% after 18 months. This study is the first to directly validate a specific set "best practices" for medication administration.


Medication error results in approximately 400,000 preventable drug-related injuries in hospitals and at least $3.5 billion in extra medical costs annually, according to the Institute of Medicine, which is part of the National Academies.


The program was developed by the Integrated Nurse Leadership Program (INLP), one of the core research and professional development programs of UCSF's Center for the Health Professions. The data will be officially released tomorrow at a graduation ceremony honoring the INLP's participants: 63 clinicians from seven Bay Area hospitals.


The INLP's 18-month program trained front-line clinicians, primarily nurses, to take a leadership role in developing clinical protocols, reporting tools and metrics, and administrative procedures. At every institution in the study group, the initiatives led by INLP participants resulted in quantifiable improvements in care.


"Because front-line clinical staff have the greatest understanding of recurrent quality issues, they are best equipped to lead improvement initiatives," said INLP Director, Julie Kliger. "Our research shows that they can deliver tremendous results, when equipped with the right skills, authority, and executive support."


The Program, which is funded by a grant from the San Francisco-based Gordon and Betty Moore Foundation, is seeking to expand its research from medication error to other clinical indicators, such as reducing sepsis through early intervention. Study results also indicate similar, significant improvements in accuracy when INLP procedures were extended from a single pilot unit into other medical units within the same institution.


"The evidence tells us that the INLP improvement model can be applied across a broad spectrum of clinical issues and settings," said Kliger. "We would even argue that the only way to achieve sustainable improvements in our healthcare system, in general, is to give a leadership role to clinicians on the front lines."


The mean "observed" medication accuracy rate showed continual improvement throughout the study period: from a baseline of 83.8% at the start of the program, to 93.0% after 18 months. "Observed" accuracy is the strictest form of assessment for medication administration, and 80% is a typical accuracy rate for hospitals nationwide, according to a forthcoming book by the Agency for Healthcare Quality and Research, titled: Advances in Patient Safety & Quality-An Evidence-based Handbook for Nurses.


INLP participants, in partnership with hospital management, focused on adherence to six process steps identified by CalNOC (the California Nursing Outcomes Coalition) as "best practices" for medication administration. This study is the first to validate CalNOC's "best practices," verifying that adherence to the six process steps delivers significant and measurable improvements in medication administration accuracy. Adherence to best practices increased from a baseline of 79.5% at the start of the program, to 95.6% after 18 months.


"These results make it clear - achieving higher quality with lower costs requires investing in people, not just technologies and facilities, and not just tinkering with 'policy,'" said Ed O'Neil, Director of UCSF's Center for Health Professions. "The best way to build a better healthcare system is to treat our front-line clinical workers as a management resource, rather than a cost center. These are experienced and essential personnel, who can identify problems, drive change, and deliver results."


- Integrated Nurse Leadership Program link.

- Center for the Health Professions link.

- Gordon and Betty Moore Foundation link.


Participating Bay Area hospitals included: Kaiser Permanente (Fremont), Kaiser Permanente (Hayward), Novato Community Hospital (Novato), San Francisco General Hospital (SF), St. Rose Hospital (Hayward), Stanford Hospital and Clinics (Palo Alto), and Sequoia Hospital (Redwood City).


(The INLP initiative is not affiliated with the current IHI initiative addressing medication reconciliation.)

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