The precise observation system for the safe use of medicines (POSSUM): an approach for studying medication administration errors in the field

Johanna I. Westbrook*, Magdalena Z. Raban, Elin C. Lehnbom, Ling Li

*Corresponding author for this work

Research output: Chapter in Book/Report/Conference proceedingConference proceeding contributionpeer-review

3 Citations (Scopus)
1717 Downloads (Pure)


Medication administration errors (MAEs) in hospital are frequent and significantly more likely to result in serious harm to patients than other medication error types. Many interventions have been proposed in order reduce MAEs and the amount of harm associated with these errors. A major limitation in assessing the effectiveness of these interventions has been the lack of robust measures for assessing changes in MAEs and associated harms. Drawing upon extensive foundational research we have developed a robust approach and data collection software to be applied in direct observational studies of nurses to allow measurement of changes in MAE rates. We report how this approach is being applied in a large stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce MAEs in a paediatric hospital.

Original languageEnglish
Title of host publicationExploring complexity in health
Subtitle of host publicationan interdisciplinary systems approach
EditorsAlexander Hoerbst, Werner O. Hackl, Nicolette DeKeizer, Hands-Ulrich Prokosch, Mira Hercigonja-Szekeres, Simon De Lusignan
Place of PublicationAmsterdam, Netherlands
PublisherIOS Press
Number of pages5
ISBN (Print)9781614996774
Publication statusPublished - 2016
EventMedical Informatics Europe (MIE) Conference at Conference on Health - Exploring Complexity (HEC) - An Interdisciplinary Systems Approach - Munich, Germany
Duration: 28 Aug 20162 Sep 2016

Publication series

NameStudies in Health Technology and Informatics
PublisherIOS PRESS
ISSN (Print)0926-9630


ConferenceMedical Informatics Europe (MIE) Conference at Conference on Health - Exploring Complexity (HEC) - An Interdisciplinary Systems Approach

Bibliographical note

Copyright European Federation for Medical Informatics (EFMI) and IOS Press 2016. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.


  • Medication administration errors
  • electronic health records
  • nurses
  • safety
  • evaluation
  • hospitals

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