JBI PACES enabled a clinician-led audit and feedback approach to improve medication administration. Using evidence-based criteria, teams identified gaps, applied GRiP-driven actions, re-audited, and sustained gains in independent second checks and patient communication.
Medication administration is one of the highest-volume, highest-risk activities in acute care. At St. Vincent’s Hospital Sydney, Clinical Nurse Consultant Rosemary Kennedy and a multidisciplinary team used JBI PACES to systematically improve the independent second check and other key steps in medication administration. Their work offers a clear blueprint for healthcare leaders seeking measurable, sustainable change grounded in evidence.
This expert insight outlines the structured approach, audit process, and outcomes achieved — plus how institutional access to JBI on Ovid® can equip teams to replicate these results at scale.
The challenge: High volume, complex risk, inconsistent practice
Medication administration was highlighted as a critical area for improvement in St. Vincent's Hospital Sydney. To address this, leaders focused on enhancing adherence to best practices, with an emphasis on the independent second check process. They implemented a comprehensive audit-and-feedback system paired with targeted behavior change strategies to drive meaningful improvements.
- Setting: 360-bed tertiary hospital
- Scale: 6,000+ medication administrations per day (~15.5 per patient)
- Signal: 371 reported medication administration incidents in 2022
- Evidence: Studies estimate 8–10% medication administration error rates in acute care*
The solution: a structured, evidence-based audit using JBI PACES
JBI PACES is purpose-built to help teams implement evidence in real clinical settings through audit, feedback, and iterative change. Kennedy’s team leveraged JBI PACES across four phases:
1) Build readiness and leadership
St. Vincent's Hospital appointed 19 local change agents, including nursing leaders and pharmacists, to drive and sustain change within the organization. A readiness assessment was conducted, incorporating a SWOT analysis and a survey of nursing attitudes and opinions. The assessment highlighted strengths such as strong sponsorship and a skilled workforce, weaknesses like time constraints, opportunities within the existing culture of safety, and threats including tight timelines and competing priorities. The assessment also confirmed widespread staff agreement that performing correct independent second checks significantly reduces risk.
2) Audit against explicit, evidence-based criteria
A modified medication administration evaluation and feedback tool, consisting of 26 items, was adopted to align with best practices, including the “five rights” and independent second-checking steps. Contextual variables, such as nurse characteristics and administration times, were also added to customize insights to local workflows.
The hospital used JBI PACES to:
- Configure the audit with predefined, evidence-based criteria
- Conduct baseline audits over 10 weeks using convenience sampling, while seeking maximum variation across medication types, routes, and timing
- Generate automated compliance dashboards to pinpoint gaps at the criterion level.
Why this matters: JBI PACES’ embedded, evidence-derived audit criteria and structured workflows reduce setup time, improve data quality, and produce transparent, comparable results.
3) Translate findings to action with GRiP
Kennedy facilitated GRiP (Getting Research into Practice) sessions to identify barriers, enablers, and practical strategies aligned with targeted behaviors.
There were three workstreams created to drive behavior change:
- Education: Developed an independent second checking video and education package
- Culture: Led unit-based conversations to strengthen psychological safety and shared accountability; launched a poster campaign on second checks and patient engagement
- IT: Escalated and resolved gaps in digital resources supporting medication safety
JBI PACES advantage: The GRiP workflow inside JBI PACES connects audit gaps to actionable change plans, assigns ownership, and tracks follow-through.
4) Re-audit and sustain gains
The team repeatedly used the same criteria and methods to measure changes over three separate time periods. They observed improvements in second-check adherence across multiple time points:
- Independent, unprimed second checks: Ensuring that second checks were conducted independently without prior priming
- If a second check was required, witness preparation: Both nurses were present to witness the preparation of medication administration.
- If a second check was required, perform administration at bedside: Both nurses went to the bedside to perform the second check during medication administration.
- Nurse-patient communication: Nurses asked patients if they knew what the medication was for and provided explanations if the patients were unclear.
As part of St. Vincent's Hospital's sustainability actions, they incorporated the second checking video into nursing orientation and updated the medication administration policy and competencies to align with evidence-based practices. Additionally, the hospital established regular feedback loops and ensured leadership visibility to maintain momentum and drive continuous improvement.
What made the approach work
Here are the key features that made the approach effective and impactful:
- Evidence-first audit criteria: JBI PACES provides ready-to-use, evidence-based measures that align with best practice recommendations, ensuring rigor from day one.
- Transparent reporting: Visual compliance dashboards focus teams on specific gaps and reduce ambiguity in decision-making.
- Behavior change methodology: GRiP operationalizes barrier/enabler analysis and connects it to concrete strategies.
- Multilevel sponsorship: Executive, nursing leadership, and unit-level engagement enabled faster adoption and problem-solving.
- Built-in sustainability: Orientation, policy updates, and competency checks translated short-term gains into long-term standards.
Institutional enablement with JBI on Ovid
Organizations that want to scale this approach benefit from institutional access to JBI on Ovid. The JBI tools streamlines end-to-end evidence-based practice (EBP) and quality improvement:
- JBI PACES: Process-driven QI software for audit and feedback, GRiP-driven change, and dynamic reporting
- JBI EBP Database: Curated, continually updated content—including evidence summaries, best practice procedures, and synthesized guidance — to inform audit criteria and point-of-care decisions
- JBI SUMARI: A comprehensive toolset for systematic reviews, ensuring education and research programs have a rigorous, reproducible path from protocol to publication
Together, these solutions help clinicians, educators, and administrators bridge research and practice while improving compliance, outcomes, and workforce capability.
Practical takeaways for healthcare leaders
Based on her extensive experience, Kennedy shares these key takeaways for driving sustainable improvement in healthcare:
- Start with explicit criteria; use JBI PACES’ evidence-based audit items to remove guesswork and maintain consistency across units.
- Pair data with facilitation; GRiP sessions translate numbers into action by surfacing barriers and co-designing workable solutions.
- Build behavior change into operations; embed training in orientation, align policies and competencies, and maintain visible leadership support.
- Re-audit on a schedule; verify progress and identify drift early to keep improvements on track.
- Equip your teams; institutional access to the JBI Complete Collection on Ovid ensures clinicians and educators have current, peer-reviewed resources at their fingertips.
Conclusion: A repeatable model for measurable improvement
Rosemary Kennedy’s medication administration project demonstrates how JBI PACES enables clinicians to audit practice, identify precise gaps, and implement evidence-based improvements that sustain. With institutional access to JBI on Ovid — anchored by the JBI Complete Collection—organizations can replicate this model across priority areas, strengthen compliance, and improve patient outcomes with confidence.
Next step: Explore institutional access to JBI resources on Ovid to equip your teams with the tools, evidence, and workflows that turn improvement goals into measurable results.
