Ensuring that medications are administered accurately is a priority at UCSF.  In 2008, the Department of Nursing initiated the Medication Administration Accuracy Project (MAAP) with the goal of standardizing the medication administration process in order to eliminate nursing medication errors.  Our vision is to establish and sustain best practices so that every patient receives safe, excellent quality of care.

Medication administration accuracy is achieved by standardizing the administration process so that all nurses are administering medications in the exact same way.  Standardization is achieved by focusing on practices that increase compliance with the “five rights” (right patient, right drug, right dose, right time and right route) and the “six processes,” which include the following: 

Compares medication with medication administration record
Limits distractions while passing medication
Ensures medication is labeled from dispensation to administration
Checks two forms of identification before administration
Explains medication to patient and family
Charts medication immediately after administration 

Front-line Staff Lead the Way

The role that front-line nurses play in direct patient care places them in a unique position to prevent medication administration errors and gives them the insight necessary to drive significant change at the unit level.  As part of the Medication Administration Accuracy Project (MAAP), each adult patient care unit nominates a Unit Team Lead (UTL) whose role is to facilitate improvement strategies based on medication administration observation data.  UTLs coordinate monthly and annual medication administration observation audits that involve front-line nurses observing one another administering medications and documenting adherence with the six processes of safe medication administration.  In addition, nurses educate patients regarding what to expect during a medication pass so that they too can play an important role as partners in their care. We believe that safe medication administration is a nursing imperative and that nurses at UCSF are taking charge and leading the way! 

Utilizing Innovative Technologies to Prevent Medication Administration Errors

UCSF uses “smart pumps” and ensures that all infusion pumps are programmed with the latest technology.  We have also begun to implement bar coding technology to ensure that labs are drawn correctly and medications are administered accurately.  In addition, we utilize special infusion pumps for high-risk medications such as patient controlled analgesia and epidural pain therapies.      

Data Transparency and Analysis

Observation data which measures medication administration processes and outcomes is shared on a monthly and annual basis with all staff.  UTLs review their data, identify opportunities and initiate and evaluate improvement interventions based on their data.  In addition, the Department of Nursing collaborates with the Department of Pharmacy to create and review medication reports with data aggregated at the unit level. 

Sources: Adult Division inpatient (Parnassus campus) medication administration process observations as defined by the Collaborative Alliance for Nursing Outcomes (CALNOC). Compliance rates are calculated based on 1200 dose observations per year.