Center News


Medication Administration Error Reduced at Six Bay Area Hospitals in INLP Study

October 27, 2009

A 36-month demonstration program at the University of California San Francisco (UCSF) today reported an 87.7% reduction in medication administration errors – increasing medication administration accuracy to 98% at six Bay Area hospitals. An expanded cohort of 56 units in 9 hospitals showed similar results over the course of 13 months, from September 2008 to October 2009.

According to the study, the increase in accuracy can be linked directly to better adherence to six “best practice” procedures for medication administration identified by CalNOC (the California Nursing Outcomes Coalition). Participating hospitals showed an 80.5% improvement in adherence to CALNOC best practices. Combined improvement – for administration accuracy and adherence to best practices – was 81.4% for the study group. These results confirm earlier results announced at the program’s 18-month halfway point in February 2008.

“These results prove beyond any doubt that front-line clinicians are instrumental to improving the quality, safety and efficiency of American healthcare,” said Ed O’Neil, Director of UCSF’s Center for the Health Professions. “Front-line clinical workers have to be seen as a management resource, not a cost center. These are experienced essential personnel, who can identify problems, drive change, and deliver results.”

The clinical improvement model was developed and supervised by the Integrated Nurse Leadership Program (INLP), one of the core research and professional development programs of UCSF’s Center for the Health Professions.

“Achieving higher quality with lower costs requires investing in people, not just technology and facilities,” said INLP Director, Julie Kliger. “Policymakers and healthcare institutions need to recognize front-line clinicians as a tremendous but under-utilized resource that can make a huge difference in patient care. They have the greatest understanding of recurrent quality issues, so they are best equipped to lead improvement initiatives. And our research shows that they can deliver impressive results, when equipped with the right skills, authority, and executive support.”

The preliminary data were released today at an INLP graduation ceremony honoring 284 clinical participants from nine hospitals. The final data results [Kaiser Permanente Fremont, Kaiser Permanente Hayward, San Francisco General Hospital, Sequoia Hospital, St. Rose Hospital, and Stanford Medical Center] will be published next month in the December 2009 issue of The Joint Commission Journal on Quality and Patient Safety. The INLP’s 36-month program ran from September 2006 to September 2009 and trained front-line clinicians (primarily nurses) to take a leadership role in developing new clinical protocols, reporting tools and metrics, and administrative procedures – all focused on medication administration safety and accuracy.

At every institution in the study group, the initiatives led by INLP participants resulted in quantifiable improvements in care. Study results also indicate similar, significant improvements in accuracy when INLP procedures were extended from a single pilot unit into other medical units within the same institution.

            “The evidence tells us that the INLP improvement model can be applied across a broad spectrum of clinical issues and settings,” said Kliger. “We would even argue that the only way to achieve sustainable improvements in our healthcare system, in general, is to give a leadership role to clinicians on the front lines.”

            With a new round of multi-million dollar funding from the Palo Alto-based Gordon and Betty Moore Foundation (nearly $7 million in May 2008), the INLP has expanded its research initiative to include other clinical indicators, such as reducing sepsis through early intervention.   “We are so impressed with the improvements and want to congratulate all of the participants of INLP, as well as the hospitals who have invested in their staff to make care better and safer for their patients.  We also want to congratulate UCSF for successfully designing and leading this improvement effort,” said George W. Bo-Linn, MD, Chief Program Officer at the Gordon and Betty Moore Foundation.

          Medication error results in approximately 400,000 preventable drug-related injuries in hospitals and at least $3.5 billion in extra medical costs annually, according to the Institute of Medicine, which is part of the National Academies.

            The mean “observed” medication accuracy rate for participating institutions showed continual improvement throughout the study period: from a baseline of 83.8% at the start of the program, to 93% after 18 months, to 98% after 36 months. “Observed” accuracy is the strictest form of assessment for medication administration, and 80% is a typical accuracy rate for hospitals nationwide, according to the book by the Agency for Healthcare Quality and Research, titled: Advances in Patient Safety & Quality—An Evidence-based Handbook for Nurses.

            INLP participants, in partnership with hospital management, focused on CalNOC “best practices,” and this is the first to validate that adherence to the six process steps delivers significant and measurable improvements in medication administration accuracy. Adherence to best practices increased from a baseline of 79.5% at the start of the program, to 95.6% after 18 months, and held steady at 96% after 36 months.

Integrated Nurse Leadership Program link.

Center for the Health Professions link.

Gordon and Betty Moore Foundation link.

Data Fact Sheet link

            Participating Bay Area hospitals included:  Kaiser Permanente (Fremont), Kaiser Permanente (Hayward), Contra Costa County Medical Center, San Francisco General Hospital (SF), St. Rose Hospital (Hayward), Stanford University Hospital and Clinics (Palo Alto), San Mateo Medical Center, UCSF Medical Center, and Sequoia Hospital (Redwood City).

            (The INLP initiative is not affiliated with the current IHI initiative addressing medication reconciliation.)