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QI In Action: Introducing Safe Single-checking of Low-risk Medication to Improve Nursing Workflow for Medication Administration in Paediatric Patients
We spotlight Sophie Sennar's project aimed to improve workflow for medication administration at Women’s and Children’s Health Network.
The ACHS Improvement Academy’s Quality Improvement Lead (QIL) Program supports healthcare professionals in implementing data-driven improvement initiatives within their organisations.
QIL Graduate, Sophie Sennar’s project titled, ‘Introducing Safe Single-checking of Low-risk Medication to Improve Nursing Workflow for Medication Administration in Paediatric Patients,’ aimed to streamline nursing workflow, enhance staff satisfaction, and maintain medication safety by safely implementing single-checking of low-risk medications in a paediatric setting at the Women’s and Children’s Health Network, South Australia.
Why Change Was Needed: Tackling Medication Errors Head-On
At the Women’s and Children’s Health Network (WCHN), medication administration errors were the most commonly reported medication issue, with around 80% of cases linked to failures in the checking process.
Studies have shown that when the checking of medicine is completed independently this can help reduce errors. However, in the case at WCHN, most of the checking were conducted as a primed-double check, where the first checking clinician shares information with the second checking clinician. This was often ineffective as it led to errors because of confirmation bias, deference to authority and automatic processing. Moreover, the process was time-consuming and often led to workflow interruptions.
The aim of the project was to introduce safe single-checking of low-risk medications for paediatric patients to improve the workflow of nurses who are administering medications and to increase staff satisfaction with the medication administration process, without seeing any increase in harm from medication errors.
How the Project Took Shape
The first phase of the project involved staff workshops, observation of clinical practice and a staff survey. A focus group identified various challenges with medication administration including time constraints, staff constraints, competing priorities and stock issues.
The second phase encompassed the practice change and its evaluation post-implementation. Key improvement actions included enhancing access to resources within medication rooms, implementing a QR Code staff survey to gather timely feedback, and providing regular ward updates to maintain engagement. In addition, consumers were surveyed to seek their perceptions of current medication administration process. A list of staff eligible to perform single checking was developed to ensure safety and consistency, and consumer surveys were used continued to monitor patient and family perceptions throughout the project.
Workflow, Satisfaction, and Safety Gains
The introduction of safe single-checking led to improved nursing workflow, greater staff satisfaction, and more medications being administered on time, without any increase in reported incidents. Nurses reported stronger teamwork, enhanced medication knowledge, and a greater sense of accountability. A consumer survey identified a 16% improvement in receiving medications on time. The initiative was widely accepted, with all participating staff supporting its continuation. The safe single-checking project was subsequently trialled in two other paediatric wards, with both wards reporting similar outcomes to the pilot ward.
The Medication Safety Committee and Nursing and Midwifery Clinical Council have since endorsed the rolling out of single-checking of low-risk oral medications to all hospital paediatric areas.
Explore projects from QIL Program Graduates
You can read more projects like this in the QIL Projects Summary booklet undertaken by QIL 2024 participants over the course of our 9-month program.
The QIL program enabled me to embed quality improvement tools and strategies to ensure that I was able to undertake projects and empower other clinicians along the way.
- Sophie Sennar, QIL Participant
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