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Service Delivery Innovation Profile

Real-Time, Resident-Specific Medication Information and Alerts, Supported by Medication Safety Teams, Enhance Efficiency and Reduce Medication Errors in Nursing Homes

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As part of a research study, five nursing homes implemented an electronic medication administration record system that provided real-time, resident-specific medication management information and alerts for those administering medications. The nursing homes also established multidisciplinary medication safety teams to maximize the impact of the new system. The program enhanced the efficiency of medication administration and reduced medication errors significantly.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of key metrics at baseline and at 3, 6, and 9 months after implementation. Data are based on onsite observations of medication administration across multiple shifts and units at all five participating nursing homes.
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Developing Organizations

University of Missouri-Columbia
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Date First Implemented

The research study was conducted from 2003 to 2007, and ended following the completion of grant funding.begin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

At least 1.5 million preventable medication errors occur in the United States each year.1 Frail nursing home residents are at especially high risk of adverse effects from such errors.2,3
  • A common problem: Although errors are common across all stages of the medication process, they occur most frequently during prescribing and administration.1 Research suggests that errors occur in 10 percent or more of all administered doses (not including wrong-time errors).4
  • Adverse effects for frail elderly: Nursing homes provide care to elderly residents who are often frail and vulnerable, leaving them at increased risk for negative consequences from even relatively minor errors in medication administration.3,5 Many nursing home residents are medically complex and take a number of prescribed medications each day. If administered incorrectly, these medications can cause significant problems, including adverse drug interactions and side effects.
  • Unrealized potential of process improvements: Medication administration in nursing homes often involves a complicated series of decisions and actions performed by both internal and external staff who work in a variety of roles. Making efforts to understand and continually improve these complex structures and processes can help to prevent medication errors,6 but relatively few nursing homes engage in such activities.

What They Did

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Description of the Innovative Activity

As part of a research study, five nursing homes implemented an electronic medication administration record system that provided real-time, resident-specific medication management information and alerts for those administering medications. The nursing homes also established multidisciplinary medication safety teams to maximize the impact of the new system. The research study concluded in 2007 following the completion of grant funding. Key elements of the program included the following:
  • Electronic medication administration record system: Designed by an external vendor as a part of a larger electronic health record, this system directed and recorded medication administration at the point of care, primarily through a touchscreen application accessed via a wireless laptop computer. The system could also be accessed at electronic health record terminals installed at nursing stations and in the offices of clinical leaders, thus allowing for the integration of information among physicians, nurses, medication administrators, and nursing home leaders. Key functions provided by the system are outlined below:
    • Medication management: Nurses were able to enter all medication and dosage information, including corrections and additions, into the system, which, in turn, provided real-time, resident-specific information on active orders. This allowed the medication administrator to focus on the medications due within the next hour. Color-coded alerts helped to identify new orders and instances when a medication was due, past due, or required followup. Previously, medication administrators had to search through 30 days of paper records to identify current prescriptions and dosages for each resident.
    • Streamlined ordering: Nurses could input new medication orders from offsite practitioners directly into the system, which then printed a detailed report to be faxed to the pharmacy. Previously, nurses had to rewrite new orders by hand up to five times before sending them to the pharmacy. Streamlining this process eliminated a number of steps, thus reducing opportunities for error.
    • Reports for leadership: Nursing home leaders could use the system to access reports on critical safety issues, such as late or missed medications and timing and volume of high-risk medications. These reports allowed leaders and administrators to better organize work flow and identify opportunities for improvement.
  • Medication safety teams: Each participating nursing home established a multidisciplinary medication safety team to facilitate implementation and integration of the system. The team included four to six nursing home staff with primary responsibility for medication administration (e.g., registered nurses, licensed practicing nurses, and certified medication technicians), nursing home leaders, a pharmacy representative, and, if applicable, the designated nurse responsible for quality improvement. The teams met monthly over the course of 2 years, facilitated by a member of the research team. Team activities included the following:
    • Education and discussion: Medication safety teams held discussions on a number of topics related to medication safety, including what constitutes a medication error, the implications of reporting such errors, and how understanding medication errors can lead to improved processes. They also reviewed facility-specific barriers to medication safety that had been identified in earlier focus groups (see Planning and Development section for more information on these groups) and discussed how they might use the system to overcome these barriers.
    • Ongoing monitoring of medication safety: Medication safety teams conducted monthly reviews of known medication errors (both reported and observed), and reviewed reports from the research team on various types of medication errors, including early and late administration, missed medications, and incorrect dosing, routing, and preparation. Using this information, the teams closely monitored the use of the new system, including its impact on related processes and communication patterns. The goal was to maximize the positive impact of the new system on medication safety.
    • Quality improvement initiatives: Teams at several participating nursing homes launched projects designed to improve inefficient processes related to medication administration. For example, one nursing home had been experiencing problems with the timely administration of medications due to delays from a third-party delivery system, which led to many late or omitted doses. Using a report from the new system on missing medications, the team worked with the pharmacy and third-party delivery system to expedite delivery, identified in-house medications (e.g., antibiotics) that could be substituted in the event of a delayed delivery, and informed staff how to access these medications when needed.2

Context of the Innovation

Founded in 1839, the University of Missouri-Columbia is Missouri's largest public research university. The five participating nursing homes, which were chosen to be representative of the diversity of homes in the area, ranged in size from 60 to 400 beds, and included two rural and three urban facilities. The program began after the principal investigator, Dr. Scott-Cawiezell (then an assistant professor at the university's Sinclair School of Nursing), spent years working as a research consultant to the Centers for Medicare & Medicaid Services, guiding work on quality improvement and patient safety. As a part of this and other professional ventures, Dr. Scott-Cawiezell spent significant time in nursing homes, observing firsthand the challenges to medication safety created by the traditional, paper-driven administration process. Believing that technology could improve the situation, she sought funding to develop the clinical protocol and test an electronic medication administration record system in a variety of nursing home settings. The leaders of all five homes expressed a willingness to implement and test this type of advanced, interactive technology.

Did It Work?

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The program enhanced the efficiency of medication administration and reduced medication errors significantly.
  • Enhanced efficiency: The average number of medications administered per hour by each administrator rose from 40 at baseline to 57 nine months after implementation.2
  • Fewer medication errors: The percentage of medications delivered late fell from 22.3 percent at baseline to 15.1 percent 6 months after implementation. During this same time period, the percentage of medications with dosing errors fell by half, from 1.2 to 0.6 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of key metrics at baseline and at 3, 6, and 9 months after implementation. Data are based on onsite observations of medication administration across multiple shifts and units at all five participating nursing homes.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Obtaining funding: The research team sought and obtained a 4-year Patient Safety Challenge Grant from the Agency for Healthcare Research and Quality.
  • Recruiting nursing homes: Researchers used existing relationships to recruit nursing homes that represented rural and urban settings, various sizes, and various ownership structures (for profit, not for profit, and faith based).
  • Partnering with vendor: The team partnered with an external vendor to set up and facilitate the technology. The vendor had an existing relationship with the University of Missouri, having already provided technologic support for a previous project where computer-based documentation was implemented in nursing homes.
  • Conducting informant interviews and focus groups: The research team conducted key informant interviews and focus groups with 76 individuals to explore staff perceptions about medication safety and to gather information about existing medication administration processes and problems. At each site, researchers interviewed nurse leaders and project coordinators, and conducted two focus groups. The first focus group included staff responsible for medication management, including registered nurses, nurse case managers, pharmacy consultants, and offsite pharmacists. The second focus group consisted of staff who routinely administer medications, including licensed practicing nurses and certified medication technicians.
  • Selecting medication safety team members: Based on observations during initial site visits, informant interviews, and focus groups, the research team invited staff to serve on medication safety teams at each nursing home. Researchers chose staff who demonstrated a sound understanding of the medication administration process and who appeared to be informal leaders among their colleagues.
  • Training: The external vendor provided approximately 12 hours of initial training on the new system for nursing home staff and continued to provide ongoing training and support as issues arose.

Resources Used and Skills Needed

  • Staffing: The research team consisted of a principal investigator, program coordinator, and two research nurses. Several additional colleagues at the University of Missouri assisted with data analysis, as needed. Between four and six staff members at each nursing home participated on medication safety teams as part of their regular duties.
  • Costs: The research project budget totaled $1.5 million over the 4-year study period, with the bulk of the cost related to development and implementation of the electronic medication administration record system.
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Funding Sources

Agency for Healthcare Research and Quality
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Adoption Considerations

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Getting Started with This Innovation

  • Maintain good working relationship with vendor: Maintaining two-way communication allows the user to alert the vendor of any quirks or issues that arise while letting the vendor inform the user of any new system developments or updates.
  • Build trusting relationships between researchers and staff: As part of the project, researchers must be seen by nursing home staff as both knowledgeable and nonjudgmental. Staff will be less likely to share information about errors if they fear repercussions.

Sustaining This Innovation

  • Support safety teams: Invest significant time and energy into arming medication safety teams with information that enables them to maximize and sustain the positive benefits from the system.
  • Build organizational capacity: Use the system and the data it generates as tools to encourage ongoing communication, teamwork, and leadership in the area of medication safety.
  • Focus on improvement, not blame: Use the information generated by the system to improve safety for nursing home residents, not to identify and blame staff who commit errors.

More Information

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Contact the Innovator

Jill Scott-Cawiezell, PhD, RN, FAAN
University of Iowa College of Nursing
101 Nursing Building
50 Newton Road
Iowa City, IA 52242
(319) 335-8210

Innovator Disclosures

Dr. Scott-Cawiezell has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; information on funders is available in the Funding Sources section.

References/Related Articles

Scott-Cawiezell J, Vogelsmeier A, McKenney C, et al. Moving from a culture of blame to a culture of safety in the nursing home setting. Nurs Forum. 2006;41(3):133-40. [PubMed]


1 Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2006. Available at:
2 Scott-Cawiezell J, Madsen RW, Pepper GA, et al. Medication safety teams' guided implementation of electronic medication administration records in five nursing homes. Jt Comm J Qual Patient Saf. 2009;35(1):29-35. [PubMed]
3 Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34. [PubMed]
4 Barker KN, Allan EL. Research on drug-use-system errors. Am J Health Syst Pharm. 1995;52(4):400-3. [PubMed]
5 Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. American J Med. 2005;118(3):251-8. [PubMed]
6 Vogelsmeier A, Scott-Cawiezell J, Zellmer D. Barriers to safe medication administration in the nursing home—exploring staff perceptions and concerns about the medication use process. J Gerontol Nurs. 2007;33(4):5-12. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 10, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.