This landmark report, often cited by many in health care, offers some solutions to prevent harm to patients. Choose two of these strategies and discuss the progress we have made to date.

            The designated article discussed many ways to ensure and maintain safety in various areas of the health care arena particularly those within a health care organization. The first strategy mentioned which has had a large impact on the nurses within my institution is the implementing of safety systems within our health care organization to ensure safe practices at the delivery level (November 1999). Such improvements being utilized by the hospital to maintain safety include precautions such as the use of designated hospital pass codes for patient-controlled analgesic (PCA) pumps in addition to narcotic lock key to access medications. This double measure helps to prevent errors as it relates to narcotic medications. In addition to multiple safety codes to prevent narcotic errors, it is also requiring that two registered nurse verification for high risk meds such as insulin, narcotics, magnesium, potassium, and blood products to name a few. In the past intravenous fluid drip rates were calculated manually by the nurse, today as a method to prevent any errors as it relates to intravenous fluids, hard locks for high risk IV medications to prevent the possibility of issues such as fluid overload and inaccurate administration rate on IV pumps have been implemented by the institution. 

To ensure correct medication administration, the institution as also initiated a four-step process when administrating medication; verification of name, medical record number, DOB, and checking arm and allergy bands when administering medications. Professionals have been encouraged to utilize the risk-free incident report system, to monitor and further implement interventions to eliminate medication errors. Many errors are not reported due to factors such as lack of awareness that an error actually occurred, unfamiliarity with the medication, and fear of personal and legal penalties associated with a medical error (Godshall & Riehl, 2018). Hence the utilizing of this risk-free type of reporting system.

The second strategy the article suggested included raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care. We have progressed by implementing and offering quarterly certification courses for administration of medications such as chemotherapy and providing in-services on new products and maintaining competency by providing periodic competency courses to staff to ensure continued comfort levels of staff who will need to operate these new devices.



Godshall, M., & Riehl, M. (2018, September). Preventing medication errors in the information age … Retrieved from