Implementation of a Medication Near-Miss Reporting System

Author

Jamie DeubelFollow

Date of Award

Spring 5-10-2019

Document Type

DNP Project

Project Team Faculty Member

Dr. Cynthia Schmidt

Project Team Faculty Member

Dr. Kevin Stein

Project Team Faculty Member

Dr. Michelle Ertel

Keywords

Near-miss, Medication reporting system, near-miss reporting, anesthesia

Abstract

Faculty from a state university nurse anesthesia program requested a system to track medication near-miss events among their students. After a literature review, and in collaboration with faculty stakeholders, an electronic medication near-miss reporting system was developed and activated. A Likert scale evaluation survey was designed and reviewed by experts. This medication near-miss survey was auto-populated for all students who utilized the system. Students were happy with the anonymity, ease of use, and time it took to report the near-miss. Faculty stakeholders were given an open-ended question survey and results indicated faculty were pleased with the data they received. After some revisions, the faculty plan to continue to utilize the system for all errors, not only those meeting a “near-miss” definition. Results from this project will allow changes to be made in the curriculum to better address medication errors. The most impactful finding was the importance of debriefing after a near-miss event. Faculty plan to ensure that students are a part of a debriefing after medication near-miss events and errors, since many students found it beneficial. The reporting system also provided details about the drugs and situations that were most frequently part of the near-miss events.

Recommended Citation

Deubel, Jamie, "Implementation of a Medication Near-Miss Reporting System" (2019). Doctor of Nursing Practice Projects. 38.
https://spark.siue.edu/dnpprojects/38

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