QI in Action: Reducing Medication Errors Through Targeted Improvement
We spotlight Nicole Michelsen's project aimed to improve medication administration safety at Fiona Stanley Fremantle Hospital.
The ACHS Improvement Academy’s Quality Improvement Lead (QIL) Program supports healthcare professionals in implementing data-driven improvement initiatives within their organisations.
QIL Graduate, Ms Nicole Michelsen’s project titled, ‘Project Zero Omissions,’ tackled one of the most common safety concerns in healthcare—medication administration errors. By analysing local incident data, identifying root causes, and implementing targeted interventions, the project aimed to reduce missed doses and omissions.
Fiona Stanley Fremantle Hospitals Group delivers hospital and community-based public health to a population of more than 698,616 across the southern half of Perth. Services at Fiona Stanley Fremantle Hospitals Group comprise of Fiona Stanley Hospital, Fremantle Hospital and Rottnest Island Nursing Post.
Project Background
Medication safety is critical to quality care, yet medication errors remain one of the most frequently reported safety concerns across healthcare settings in Australia. At the Fiona Stanley Fremantle Hospital Group, analysis of local incident data revealed that medication-related events represented the highest proportion of clinical incidents, with administration to patient errors accounting for around 70% of all medication incidents. In addition, failures to administer and omissions made up an alarming 43%, signalling an urgent need to strengthen medication administration processes.
The high rate of omissions and missed doses not only affects patient outcomes but can also prolong hospital stays, reduce the effectiveness of treatment, and increase costs. Recognising the risk and opportunity for improvement, the project set out to improve medication administration safety, focusing on reducing failure to administer and omission rates by 25% within 12 months, and by 50% within two years.
Identifying Causes of Medication Errors
To build a strong foundation for change, the team began with a comprehensive diagnostic phase. Using improvement science tools such as affinity and driver diagrams, they mapped current medication administration processes and identified key factors contributing to errors. Three overarching themes were identified for medication errors:
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Contextual factors – environmental and workflow issues such as distractions, interruptions and competing priorities.
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Knowledge factors – variability in staff understanding of medication policy/ procedures and risk awareness.
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Personal factors – individual behaviours, habits, and attitudes influencing compliance.
Implementing Strategies for Change
The various causes of medication errors pointed to a need for a multifaceted approach to change interventions. Based on diagnostic findings, the team developed and implemented four key strategies aimed at strengthening medication safety and reliability:
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Implementation of ‘cockpit rules’ to reduce any distractions during critical tasks, such as medication rounds, which in turn minimises human error
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Standardising medication chart order
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Strengthening insulin administration protocols
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Introducing mid-shift medication chart checking
Education sessions and resource packs supported nursing staff through these changes.
Results
Early measurement revealed that failures to administer or omissions, as reported via the Datix Clinical Incident Management System, increased slightly compared to baseline data. This rise in reported data can be likely attributed to a heightened awareness and focus on safe medication administration among staff.
By the end of the 9-month program there was strong compliance to cockpit rules and insulin administration protocols, with continued focus needing to be directed toward improving the storage of medication charts and mid-shift chart checking.
The project has been instrumental in identifying the key factors contributing to failures to administer and omissions, paving the way for targeted interventions that strengthen medication safety. Ongoing data analysis will guide the refinement of these strategies to support sustained improvement.
Explore projects from QIL Program Graduates
You can read more projects like this in the QIL Projects Summary booklet undertaken by QIL 2021-2023 participants over the course of our 9-month program.
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