# A Memory-Based Approach to Reducing Medication Errors

> **NIH AHRQ R03** · MEDSTAR HEALTH RESEARCH INSTITUTE · 2020 · $71,223

## Abstract

PROJECT SUMMARY
Despite being widely researched, between 10 to 50% of inpatient medication administration instances are
associated with errors. Memory lapses are a common cause of medication administration errors (MAE).
Prospective memory (PM), which is remembering information that must be acted on in the future, is a frequent
memory process used by nurses during medication administration and is a potentially significant source of the
memory lapse errors. PM tasks during medication administration arise when nurses must remember to perform
important medication-related tasks in the future, such as remembering to check for interactions before
administering medication, and remembering to resume tasks that are interrupted during medication
administration. Managing PM demands in high-risk, high-volume medical/surgical units in which nurses manage
up to eight patients, with each patient being scheduled on average 25 medications per day, is especially
challenging, and may leave nurses at risk for committing MAEs. Our proposal will use a cognitive psychology-
based approach, with a focus on PM, to identify PM demands during medication administration. We will use
sociotechnical systems theory to identify high-risk moments during medication administration where PM may be
unsupported by the sociotechnical system and increase the likelihood of MAEs. We will also analyze medication
errors through data generated by technologies in the inpatient medication prescription to administration cycle
and align these data with PM demands to provide unique insights into the association between medication errors
and PM demands. Our proposed research includes the following: Specific Aim 1: Identify and quantify nurse
PM demands during medication administration through interviews and direct observations. Specific Aim 2:
Identify and quantify medication errors by analyzing technology usage data in the inpatient medication cycle (i.e.,
prescription, dispensing, administration, and documentation), and align medication errors with observed PM
demands. Identifying memory demands of nurses during medication administration presents an opportunity for
future work to develop memory aids and health information technology to support PM needs to reduce MAEs.

## Key facts

- **NIH application ID:** 9958744
- **Project number:** 1R03HS027510-01
- **Recipient organization:** MEDSTAR HEALTH RESEARCH INSTITUTE
- **Principal Investigator:** Sadaf Kazi
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2020
- **Award amount:** $71,223
- **Award type:** 1
- **Project period:** 2020-03-01 → 2022-02-28

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9958744

## Citation

> US National Institutes of Health, RePORTER application 9958744, A Memory-Based Approach to Reducing Medication Errors (1R03HS027510-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9958744. Licensed CC0.

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