Benefits of direct observation in medication administration to detect errors

Teresa Diaz-Navarlaz, Peter Pronovost, Elena Beortegui, María Segui-Gomez

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: To evaluate the nursing process of medication administration in terms of safety to identify frequency and characteristics of errors and to identify possible solutions. METHODS: Descriptive analysis data from a blinded observational study of randomly selected episodes of nursing administration medication, for which some 40 parameters each to be observed had been identified. Seventeen nurses and 88 patients from a university hospital in Navarra (Spain) participated. Patients were given 172 drugs. We measured whether errors, active failures, or latent conditions were present during the medication administration process. RESULTS: In 1075 possibilities of errors (the total number of medications administered to the patients multiplied by the processes to be observed), we detected 1 error and 474 active failures. Interestingly, no failures were observed in processes that had already been computerized. CONCLUSIONS: Human behavior modifies the process of medication administration. A change is proposed because several processes and infrastructure-related variables can be improved, thus changing the system and conditions under which nurses work. A specific strategy of change has been proposed and is currently being piloted in a ward. This includes structural modifications and nurse training.

Original languageEnglish (US)
Pages (from-to)200-207
Number of pages8
JournalJournal of patient safety
Issue number4
StatePublished - Dec 2007
Externally publishedYes


  • Drugs error
  • Medication administration
  • Nursing
  • Safety

ASJC Scopus subject areas

  • Leadership and Management
  • Public Health, Environmental and Occupational Health


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