Date of Award

Spring 4-4-2016

Document Type


Degree Name

Doctor of Nursing Practice (DNP)




Kay Ball, PhD, RN, CNOR, FAAN

First Committee Member

Jacqueline Haverkamp, DNP, RN, CNP

Second Committee Member

Monica Nayar, PharmD

Third Committee Member

Colette Wolf, MSN, RN, CPPS


Medication Error, Near Miss, Self Report, Anesthesia, Patient Safety

Subject Categories

Medicine and Health Sciences | Nursing | Perioperative, Operating Room and Surgical Nursing


There is currently no emphasis being placed on the significance of reporting medication errors, including near misses, for the anesthesia department in a Midwestern hospital system. Efforts to ensure patient safety depend upon collecting data related to actual medication errors, including near misses, so that educational or process improvement opportunities can be identified and implemented. The focus of this quality improvement project was to educate anesthesia providers about the importance of properly reporting all medication errors and near misses. The pre and post survey helped to provide data to determine whether anesthesia providers believe they are more apt to report medication errors and near misses after attending an educational session.

An online or face-to-face educational session was conducted for all anesthesia providers in the anesthesia department in a specific Midwestern hospital system. Results from the pre and post test showed statistically significant data (P – value < 0.05) that anesthesia providers believe reporting medication errors and near misses improves patient safety (P = 0.043), education about the process of reporting medication errors will increase compliance in self-reporting (P = 0.018), and that fear of punishment (78%), lack of knowledge on how to use the current reporting system (75%), and fear of litigation (73%) were the top 3 barriers that kept the anesthesia providers from reporting medication errors and near misses.



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