A controlled pilot study was performed to evaluate implementation of a medication identification device intended to reduce errors in nursing homes. Naïve observation was used for data collection of medication errors on an intervention unit using the device and a control unit, along with field notes describing observation details. Ten staff were observed administering medications to 70 residents over the study time-frame. Of the 9,099 medication administrations observed ( = 4,588 intervention; = 4,511 control), 1,068 (12%) errors were identified. The intervention unit had fewer non-time errors versus the control unit, including dose ( = 21 vs. = 59; < 0.01), drug ( = 4 vs. = 21; <0.01), route ( = 0 vs. = 4; < 0.01), and given without order ( = 1 vs. = 8; < 0.01). However, time errors were higher on the intervention unit and were often due to late start and interruptions. Non-time errors were due to reliance on memory and nursing judgment. A combination of technology and staff dedicated solely to medication administration likely affected error rate differences. [(4), 5-11.].
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