Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy

Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration

BACKGROUND

Because of the high frequency of interruptions during medication administration, the effectiveness of strategies to limit interruptions during medication administration has been evaluated in numerous quality improvement initiatives in an effort to reduce medication administration errors.

OBJECTIVES

To evaluate the effectiveness of evidence-based strategies to limit interruptions during scheduled, peak medication administration times in 3 progressive cardiac care units (PCCUs). A secondary aim of the project was to evaluate the impact of limiting interruptions on medication errors.

METHODS

The percentages of interruptions and medication errors before and after implementation of evidence-based strategies to limit interruptions were measured by using direct observations of nurses on 2 PCCUs. Nurses in a third PCCU served as a comparison group.

RESULTS

Interruptions (P < .001) and medication errors (P = .02) decreased significantly in 1 PCCU after implementation of evidence-based strategies to limit interruptions. Avoidable interruptions decreased 83% in PCCU1 and 53% in PCCU2 after implementation of the evidence-based strategies.

CONCLUSIONS

Implementation of evidence-based strategies to limit interruptions in PCCUs decreases avoidable interruptions and promotes patient safety.

Medication administration and interruptions in nursing homes: A qualitative observational study

AIMS AND OBJECTIVES

To contribute in-depth knowledge of the characteristics of medication administration and interruptions in nursing homes. The following research questions guided the study: How can the medication administration process in nursing homes be described? How can interruptions during the medication administration process in nursing homes be characterized?

BACKGROUND

Medication administration is a vital process across healthcare settings, and earlier research in nursing homes is sparse. The medication administration process is prone to interruptions that may lead to adverse drug events. On the other hand, interruptions may also have positive effects on patient safety.

DESIGN

A qualitative observational study design was applied.

METHODS

Data were collected using partial participant observations. An inductive content analysis was performed.

RESULTS

Factors that contributed to the observed complexity of medication administration in nursing homes were the high number of single tasks, varying degree of linearity, the variability of technological solutions, demands regarding documentation and staff's apparent freedom as to how and where to perform medication-related activities. Interruptions during medication administration are prevalent and can be characterised as passive (e.g., alarm and background noises), active (e.g., discussions) or technological interruptions (e.g., use of mobile applications). Most interruptions have negative outcomes, while some have positive outcomes.

CONCLUSIONS

A process of normalisation has taken place whereby staff put up with second-rate technological solutions, noise and interruptions when they are performing medication-related tasks. Before seeking to minimise interruptions during the medication administration process, it is important to understand the interconnectivity of the elements using a systems approach.

RELEVANCE TO CLINICAL PRACTICE

Staff and management need to be aware of the normalisation of interruptions. Knowledge of the complexity of medication administration may raise awareness and highlight the importance of maintaining and enhancing staff competence.

A combined intervention to reduce interruptions during medication preparation and double-checking: a pilot-study evaluating the impact of staff training and safety vests

AIM

The aim was to evaluate the impact of staff training and wearing safety vests as a combined intervention on interruptions during medication preparation and double-checking.

BACKGROUND

Interruptions and errors during the medication process are common and an important issue for patient safety in the hospital setting.

METHODS

We performed a pre- and post-intervention pilot-study using direct structured observation of 26 nurses preparing and double-checking 431 medication doses (225 pre-intervention and 206 post-intervention) for 36 patients (21 pre-intervention and 15 post-intervention).

RESULTS

With staff training and the introduction of safety vests, the interruption rate during medication preparation was reduced from 36.8 to 28.3 interruptions per hour and during double-checking from 27.5 to 15 interruptions per hour.

CONCLUSION

This pilot-study showed that the frequency of interruptions decreased during the critical tasks of medication preparation and double-checking after the introduction of staff training and wearing safety vests as part of a quality improvement process.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing management should acknowledge interruptions as an important factor potentially influencing medication safety. Unnecessary interruptions can be successfully reduced by considering human and system factors and increasing both staff and nursing managers' awareness of 'interruptive communication practices' and implementing physical barriers. This is the first pilot-study specifically evaluating the impact of staff training and wearing safety vests on the reduction of interruptions during medication preparation and double-checking.

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study

Aim

To evaluate the effectiveness of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration.

Methods

A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were randomised to the intervention which comprised wearing a vest when administering medications; strategies for diverting interruptions; clinician and patient education; and reminders. Control wards were blinded to the intervention. Structured direct observations of medication administration processes were conducted. The primary outcome was non-medication-related interruptions during individual medication dose administrations. The secondary outcomes were total interruption and multitasking rates. A survey of nurses' experiences was administered.

Results

Over 8 weeks and 364.7 hours, 227 nurses were observed administering 4781 medications. At baseline, nurses experienced 57 interruptions/100 administrations, 87.9% were unrelated to the medication task being observed. Intervention wards experienced a significant reduction in non-medication-related interruptions from 50/100 administrations (95% CI 45 to 55) to 34/100 (95% CI 30 to 38). Controlling for clustering, ward type and medication route showed a significant reduction of 15 non-medication-related interruptions/100 administrations compared with control wards. A total of 88 nurses (38.8%) completed the poststudy survey. Intervention ward nurses reported that vests were time consuming, cumbersome and hot. Only 48% indicated that they would support the intervention becoming hospital policy.

Discussion

Nurses experienced a high rate of interruptions. Few were related to the medication task, demonstrating considerable scope to reduce unnecessary interruptions. While the intervention was associated with a statistically significant decline in non-medication-related interruptions, the magnitude of this reduction and its likely impact on error rates should be considered, relative to the effectiveness of alternate interventions, associated costs, likely acceptability and long-term sustainability of such interventions.

Effectiveness of an improvement programme to prevent interruptions during medication administration in a paediatric hospital: a preintervention-postintervention study

OBJECTIVE

To assess the effectiveness of an improvement programme to reduce the number of interruptions during the medication administration process in a paediatric hospital.

DESIGN AND METHODS

A prestudy-post study design was used to monitor nursing interruptions during medication cycles in a paediatric hospital. Interruptions were reported on an observation sheet (MADOS-P) adapted to the paediatric context.

SETTING

A 600-bed tertiary paediatric research hospital in Italy.

INTERVENTION

The interventions included a yellow sash worn by nurses during medication cycles, a yellow-taped floor area indicating the 'No interruption area', visual notices in the medication areas, education sessions for healthcare providers and families, patient and parent information material.

RESULTS

225 medication cycles were observed before the intervention (T0) and 261 after the intervention (T1). The median of interruptions occurring in each cycle decreased significantly from baseline to postintervention (8.0 vs 2.0, p=0.002), as the rate ratios (interruptions/patient post-pre ratio: 0.34; interruptions/medication post-pre ratio: 0.37; interruptions/hour of medication cycle post-pre ratio: 0.53, p<0.001). During preintervention, the main causes of interruptions were 'other patients' (19.9%), 'other nurses' (17.2%) and 'conversation' (15.7%); during postintervention, they were 'other nurses' (26.1%), 'conversation' (18.2%) and 'other patients' (17.4%).

CONCLUSIONS

This bundle of interventions proved to be an effective improvement programme to prevent interruptions during medication administration in a paediatric context.

Interruptions and medication administration in critical care

BACKGROUND

Medication administration has inherent risks, with errors having enormous impact on the quality and efficiency of patient care, particularly in relation to experience, outcomes and safety. Nurses are pivotal to the medication administration process and therefore must demonstrate safe and reliable practice. However, interruptions can lead to mistakes and omissions.

AIM

To critique and synthesize the existing literature relating to the impact that interruptions have during medication administration within the paediatric critical care (PCC) setting.

SEARCH STRATEGY

Key terms identified from background literature were used to search three electronic databases (Medline, CINHAL and BNI). Selected sources were critically appraised using the Critical Appraisal Skills Programme (CASP) tool.

FINDINGS

There is confusion within the literature concerning the definition of interruption. Moreover, an assumption that all interruptions have a negative impact on patient safety exists. The literature identifies the multi-dimensional nature of interruptions and their impact on medication administration and patient safety. The cumulative effect of interruptions depends on what type of task is being completed, when it occurs, what the interruption is and which method of handling is utilized. A conceptual schema has been developed in order to explicate the themes and concepts that emerged.

CONCLUSIONS

This review summarizes debates within the international arena concerning the impact of interruptions on medication administration. However, conclusions drawn appear applicable in relation to practice, education and future research to other critical care settings.

RELEVANCE TO CLINICAL PRACTICE

Findings show that no single strategy is likely to improve the negative effect of interruptions without focus on patient safety. Practice education to improve team building interactions is required that equips nurses with the skills in managing interruptions and delegating high priority secondary tasks.

Distracted Practice: A Concept Analysis

PROBLEM

Distracted practice is a growing concern for all healthcare professionals working in today's complex, technology-rich, acute care hospital environment. Distractions are a threat to patient safety, frequently cited as a contributing factor when reporting an adverse event. The number of new technologies introduced to the healthcare environment has significantly increased the number of distractions. Shrinking resources and the resultant time pressure placed on all practitioners has added to the list of human factors known to be contributing to potential errors. Delivering safe, quality care in this environment has now become a daily challenge for all members of the healthcare team. Distracted practice was found to have no consistent definition in the healthcare literature.

METHOD

Walker and Avant's method of concept analysis was used to develop a preliminary definition and model of distracted practice.

FINDINGS

This analysis includes a definition, characteristics, antecedents, and consequences of distracted practice.

CONCLUSION

More research is needed to fully understand this critical human experience of distracted practice. With additional knowledge we will be able to raise awareness and create interventions to reduce its occurrence among members of the healthcare team. This will positively contribute to the team's efforts to keep all our patients safe while in the hospital. D'Esmond.

Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses

OBJECTIVES

The aim of this study is to evaluate the nature, quality and effectiveness of educational interventions designed to increase the medication administration skills and safety of registered nurses working in hospitals.

DESIGN

A systematic review with meta-analysis.

DATA SOURCES

Intervention studies designed to increase the medication administration skills and safety of nurses, indexed in one or more databases (CINAHL, PubMed, Scopus, Cochrane, PsycInfo, or Medic), and published in peer-reviewed journals between January 2000 and April 2015.

REVIEW METHODS

The nature of the interventions was evaluated by narrative analysis, the quality of studies was assessed using the Effective Public Health Practise Project Quality Assessment Tool and the effectiveness of the interventions was ascertained by calculating effect sizes and conducting a meta-analysis.

RESULTS

A total of 755 studies were identified and 14 intervention studies were reviewed. Interventions differed by their nature, including traditional classroom training, simulation, e-learning, slide show presentations, interactive CD-ROM programme, and the use of posters and pamphlets. All interventions appeared to improve medication administration safety and skills based on original p-values. Only five studies reached strong (n=1) or moderate (n=4) quality ratings and one of them had to be omitted from the meta-analysis due unclear measures of dispersion. The meta-analysis favoured the interventions, the pooled effect size (Hedges' g) was large, 1.06. The most effective interventions were a blended learning programme including e-learning and a 60-min PowerPoint presentation. The least effective educational intervention, an interactive internet-based e-learning course, was reported in the study that achieved the only strong quality rating.

CONCLUSIONS

It is challenging to recommend any specific intervention, because all educational interventions seem to have a positive effect, although the size of the effect greatly varies. In the future, studies sharing similar contents and methods should be compared with each other.

Medication administration accuracy: using clinical observation and review of patient records to assess safety and guide performance improvement

RATIONALE, AIMS AND OBJECTIVES

Medication-related errors are common and can occur at every step of the medication process. The aim was to explore (1) the extent to which nurses perform fundamental safe practices related to medication administration (MA); (2) the frequency and characteristics of MA errors; and (3) the clinical significance of medication types (classes) subject to error.

METHODS

A descriptive, exploratory cross sectional design with point in time sampling was used combining direct observations, conducted by naïve observers, and medical record review. A convenience sample of three adult surgical units was drawn from a 1000-bed university hospital. Seventy-two patient-nurse MA encounters were observed including 306 MA doses based on a minimum sample of 100 doses per unit. The Medication Administration Accuracy Assessment developed by the Collaborative Alliance for Nursing Outcomes in the United States was used.

RESULTS

Observed adherence to MA safe practices varied between units. Identity control (9%), explaining medication to patient (11%) and medication labelled throughout the process (25%) were found to be safe practices with greatest deviation. 18% of doses involved a MA error (n = 54). Wrong time (9%) was the most common MA error, typically involving analgesics.

CONCLUSIONS

Given recent reports suggesting MA safe practices are strongly associated with MA errors, it is timely to strengthen RN awareness of the critical role of safe practices in MA safety. In nursing education, clinical examination using the six safe practices studied herein may enhance medication administration accuracy.

Comparison of medication safety effectiveness among nine critical access hospitals

PURPOSE

The rates of medication errors across three different medication dispensing and administration systems frequently used in critical access hospitals (CAHs) were analyzed.

METHODS

Nine CAHs agreed to participate in this prospective study and were assigned to one of three groups based on similarities in their medication-use processes: (1) less than 10 hours per week of onsite pharmacy support and no bedside barcode system, (2) onsite pharmacy support for 40 hours per week and no bedside barcode system, and (3) onsite pharmacy support for 40 or more hours per week with a bedside barcode system. Errors were characterized by severity, phase of origination, type, and cause. Characteristics of the medication being administered and a number of best practices were collected for each medication pass. Logistic regression was used to identify significant predictors of errors.

RESULTS

A total of 3103 medication passes were observed. More medication errors originated in hospitals that had onsite pharmacy support for less than 10 hours per week and no bedside barcode system than in other types of hospitals. A bedside barcode system had the greatest impact on lowering the odds of an error reaching the patient. Wrong dose and omission were common error types. Human factors and communication were the two most frequently identified causes of error for all three systems.

CONCLUSION

Medication error rates were lower in CAHs with 40 or more hours per week of onsite pharmacy support with or without a bedside barcode system compared with hospitals with less than 10 hours per week of pharmacy support and no bedside barcode system.

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review

Background

Medication administration errors are frequent and lead to patient harm. Interruptions during medication administration have been implicated as a potential contributory factor.

Objective

To assess evidence of the effectiveness of interventions aimed at reducing interruptions during medication administration on interruption and medication administration error rates.

Methods

In September 2012 we searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Effective Practice and Organisation of Care Group reviews, Google and Google Scholar, and hand searched references of included articles. Intervention studies reporting quantitative data based on direct observations of at least one outcome (interruptions, or medication administration errors) were included.

Results

Ten studies, eight from North America and two from Europe, met the inclusion criteria. Five measured significant changes in interruption rates pre and post interventions. Four found a significant reduction and one an increase. Three studies measured changes in medication administration error rates and showed reductions, but all implemented multiple interventions beyond those targeted at reducing interruptions. No study used a controlled design pre and post. Definitions for key outcome indicators were reported in only four studies. Only one study reported κ scores for inter-rater reliability and none of the multi-ward studies accounted for clustering in their analyses.

Conclusions

There is weak evidence of the effectiveness of interventions to significantly reduce interruption rates and very limited evidence of their effectiveness to reduce medication administration errors. Policy makers should proceed with great caution in implementing such interventions until controlled trials confirm their value. Research is also required to better understand the complex relationship between interruptions and error to support intervention design.

The effect of a five-part intervention to decrease omitted medications

PROBLEM

Nursing administrators reported that medication administration errors had continued despite the use of bar code medication administration, especially in terms of omitted medications. Nurse administrators within the study hospital identified a need to add back up safety systems in order to reduce the number of omitted medications. Interruptions and distractions were identified as leading constraints to accurate medication administration.

METHODS

This pre-post quality improvement study used a convenience sample of nurses on one medical surgical unit to observe the effect of specific protocols to decrease interruptions and distractions during medication administration. Nurses' were observed during medication administration cycles, and the medication time was measured in hours and minutes using a stop watch. The number of distractions and interruptions was counted by category. A participant survey was used to determine nurses perceptions of distractions and interruptions experienced.

FINDINGS

The five-part intervention decreased nurses interruptions and distractions by 84% compared with the control group. The results indicated the type of distractions and interruptions nurses typically experience during medication administration was highest from conversation in the environment (M = 5.0 ± 3.4) and by other personnel (M = 6.38 ± 2.6).

CONCLUSION

This process improvement project determined that a five-part protocol would reduce distractions and interruptions for nurses, save time in the process, and reduce omitted medications. Other visible symbols such as a vest with wording may show different results when combined with the other elements of the protocol. Anecdotal comments from nurses during and after observations divulged workplace issues surrounding medication delivery that may need investigation.

Spreading a medication administration intervention organizationwide in six hospitals

BACKGROUND

Six hospitals from the San Francisco Bay Area participated in a 12-month quality improvement project conducted by the Integrated Nurse Leadership Program (INLP). A quality improvement intervention that focused on improving medication administration accuracy was spread from two pilot units to all inpatient units in the hospitals.

METHODS

INLP developed a 12-month curriculum, presented in a combination of off-site training sessions and hospital-based training and consultant-led meetings, to teach clinicians the key skills needed to drive organizationwide change. Each hospital established a nurse-led project team, as well as unit teams to address six safety processes designed to improve medication administration accuracy: compare medication to the medication administration record; keep medication labeled throughout; check two patient identifications; explain drug to patient (if applicable); chart immediately after administration; and protect process from distractions and interruptions.

RESULTS

From baseline until one year after project completion, the six hospitals improved their medication accuracy rates, on average, from 83.4% to 98.0% in the spread units. The spread units also improved safety processes overall from 83.1% to 97.2%. During the same time, the initial pilot units also continued to improve accuracy from 94.0% to 96.8% and safety processes overall from 95.3% to 97.2%.

CONCLUSION

With thoughtful planning, engaging those doing the work early and focusing on the "human side of change" along with technical knowledge of improvement methodologies, organizations can spread initiatives enterprisewide. This program required significant training of frontline workers in problem-solving skills, leading change, team management, data tracking, and communication.