A Project of Applying PDCA Cycle to Improve New Nurse Medication Error in Surgical Ward

Friday, 25 July 2014

Li Hua Lee, BS1
Hsiu Hui Lei, MA2
Wei-Ping Cheng, BS2
(1)Department of Sugical Ward, Chi-Mei Medical Center, Tainan City, Taiwan
(2)Department of Surgical Ward, Chi-Mei Medical Center, Tainan, Taiwan


Medical errors are common problems in types of medical negligence. Medicine behavior is the most activating part of nursing work every day.

When accidental events happen, they affect patients’ safety, worsen patients’ condition, prolong the length of days in hospital and even result in death.The purpose of the study was to describe medical error problems and prevent new staff from abnormal medication administration.


The study used actual medication auditing process, abnormal analysis and interview for new staff.The data collection period was from March, 2013 to October, 2013. Our investigation has shown that new nurse's incorrect medication administration revealed as followsF(1) lack of standard training courses (2) lack of medication auditing process for internal reference (3) lack of knowledge and skills in medication administration (4) similar medicine were placed close to each other.


The Plan- Do- Check- Action (PDCA ) cycle was applied and multiple intervention strategies implemented, including Plan-(1)Hold continuing medication administration education (2) case studies of abnormal medication administration events (3) make DVDs of proper medication administration (4) redesign the location of similar medicine; Do- create a medication auditing process for internal reference only; Check- implement new target supervise system; Action- revise operating standards of medication administration flowchart


New nurses following the PDCA process have made less mistakes from the 24 abnormal medication administration events down to 11 ones. Auditing process rate has reached 100 percent, which represents the new staff could issue medication correctly.


By implementation of this project, nurse should be able to amend the accuracy of general medication and elevate the safety of using medication. As a result, patients will receive a better quality of nursing and share this sort of problem with other new staff.