TY - JOUR T1 - Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment JF - BMJ Open Quality JO - BMJ Open Qual DO - 10.1136/bmjoq-2020-000987 VL - 9 IS - 3 SP - e000987 AU - Jackie Ho AU - David Burger Y1 - 2020/09/01 UR - http://bmjopenquality.bmj.com/content/9/3/e000987.abstract N2 - Introduction In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration.Objective To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%).Methods Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders.Results Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750–239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855–80 928 per year).Conclusion Adopting John Kotter’s model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact. ER -