Lighting the Way to Medication Safety: Reducing Interruptions During Medication Administration in CardioThoracic Surgery

Regi Freeman, MSN, RN, CNS; Bethany Lee-Lehner, BSN, RN; Scott McKee, BSN, RN; & Jennifer Pesenecker, BSN, RN

4C Cardiothoracic Surgery Unit, University of Michigan, Ann Arbor, MIPurpose

Background

Methods

Results

Results

Discussion & Conclusion

References

• Nursing is the last line of defense against errors. • Nurses may not correlate the impact of

interruptions on the potential for adverse outcomes.

• Many nurses take pride in their ability to multitask and handle interruptions.

• Medication error rates indicated an area for improvement.

• The purpose of this study was to decrease the number of interruptions thereby reducing the incidence of medication errors.

Current literature describes significant adverse monetary and safety effects of medication errors in the inpatient hospital setting.

Reasons medication errors occur:• Unit layout• Nurse fatigue• Knowledge deficits• Inexperienced staff • Overhead pages• Physician rounds• Monitor & pump alarms• Multidisciplinary interruptions• Nurse, patient, & family questions• Workload & nurse to patient ratios

• An Observational study using a random sample of nurses administering medications to determine the number of interruptions pre and post implementation of interventions.

• Utilization of a standardized data collection tool to audit the number of interruptions. • Reported medication errors were reviewed pre and post implementation.

A bundle of safety interventions were implemented to reduce interruptions during medication administration:• Lighted lanyards worn by nursing while administering medications • Creation of a No Interruption Zone (NIZ) in the medication room• Electronic Medication Administration Record review during shift report• Scripting card to encourage dialogue between nursing staff and patients/family• Phone scripts for clerks to triage calls• Patient education via brochures and signs• Letters to stakeholders regarding initiatives

Pre-intervention observations:• Interruptions averaged 3.29 times during medication

administration.• An average of 1.36 interruptions occurred during IV

push medication administration. • Patients, nurses, and family were the top 3 causes of

interruptions pre-interventions.

Post-intervention Observations:• Interruptions average of 1.18 times during medication

administration.• An average of 1.25 interruptions occurred during IV

push medication administration. • Patients, nurses, and pagers were the top 3 causes of

interruptions post-interventions.

The number of medication errors reported each month displays a downward trend since implementation.

• Implementing interventions can reduce the interruptions during medication administration.

• Reducing interruptions may decrease the number of medications errors that occur and can improve medication safety.

• Continued education, reminders, and auditing will provide continuous medication safety improvement.

1. Conrad, C., Fields, W., McNamara, R., & Cone, M. (2010). Medication room madness: Calming the chaos. Journal of Nurse Care Quality, 1-8.2. Crimlisk, J. T., Johnstone, D. J., & Sanchez, G. M. (2009). Evidence-based practice, clinical simulations workshop, and intravenous medications: Moving toward safer

practice. MEDSURG Nursing, 18(3), 153-160.3. Faye, H., Rivera-Rodriguez, J., Karsh, B. T. et al. (2010). Involving intensive care unit nurses in a proactive risk assessment of the medication management process.

The Joint Commission Journal on Quality and Patient Safety, 36(8), 376-384.4. Kliger, J. (2010). Giving medication administration the respect it is due. Archives of Internal Medicine, 170(8). Retrieved on June 17, 2010 from:

www.archinternmed.com. 5. McBride-Henry, K., & Foureur, M. (2007). A secondary care nursing perspective on medication administration safety. JAN Original Research, 58-66.6. Nguyen, E. E., Connolly, P. M., Wong, V. (2010). Medication safety initiative in reducing medication errors. Journal of Nursing Care Quality, 25(3), 224-230.7. Trbovich, P., Prakash, V., Stewart, J. et al. (2010). Interruptions during the delivery of high-risk medications. The Journal of Nursing Administration, 40(5), 211-218.

0

0.5

1

1.5

2

2.5

3

3.53.29

1.361.18 1.25

Interruptions During Medication Administration

PrePost

Oral Medications IV Push Medication

Num

ber o

f Int

erru

ption

sN=59 N=47 N=14 N=4

Patient RN Family Pager0

10

20

30

40

50

60

70

Leading Types of Interruptions

Num

ber o

f Int

erru

ption

s

Impetus for change

Obtained grant funding

Planning

Education

Medication safety initiatives implemented