Date of Graduation

Fall 12-12-2014

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Medication administration is a multistep process that involves prescribing, transcribing, dispensing, and administering drugs. The transcription of medication orders during patient admissions have been described as an error prone process by nurses on the unit. An FMEA analysis and unit surveys indicated a need for improvement. The specific aim for this project is to improve the mediation transcription process for new patients with 100% participation from all staff by December 1, 2014. Based on the microsystem system analysis and the research on evidence, strategies approved for testing include mandating the double checking new mediations with another nurse, omitting the use of abbreviations on all high alert medications, and implementation of nonpunitive medication error reporting and tracking system. The new implementation strategies for improving the medication transcription process launched in October, 2014 for duration four weeks. Staff teaching on the new guidelines as well as the benefits of the new process was given and huddles at the beginning of each shift during the testing phase clarified roles, functions and processes of the test objective. The project’s theoretical framework was centered on the Change theory by Kurt Lewin known as the unfreezing-change-refreezing model. The chart audits indicated a participation rate of 80%. The survey indicated an overall positive attitude on the testing strategies. Two possible medication errors were intercepted using the project guidelines. The team recommends starting a larger scale PDSA cycle and revise educational tools to increase staff participation.