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November-December 2017 • Vol. 26/No. 6374

Janet Tompkins McMahon, DNP, RN, ANEF, is Clinical Associate Professor of Nursing, Towson University, Towson, MD; and Nurse Educator-Integration Specialist, ATI Nursing Education.

Improving Medication Administration Safety in the

Clinical Environment

W ork interruptions create danger at the bedside, particularly during med-

ication administration. A work interruption can be as simple as a telephone call, noise, or an invita- tion to conversation by a member of the healthcare team, patient, or family member while the nurse is preparing medications. Medication errors are a major concern for patients and can lead to unneces- sary safety risks (Karavasiliadou & Athanasakis, 2014). Reduction of interruptions and associated errors with medication administration is essential.

Project Site and Reasons for Change

The identified need for change was reduction of errors and distrac- tions during medication administra- tion. The current use of a no-inter- ruption zone on a medical-surgical unit was identified by the project leader as an area for improvement based on repeated observations of nurses’ nonadherence to the zone during eight random visits. Nurses, other unit staff, and interprofession- al team members appeared unaware of or ignored the purpose of the no- interruption zone.

Some institutions have adopted use of medication safety vests for nurses to wear to alert colleagues and patients of their involvement in medication administration. Accord – ing to Williams, King, Thompson, and Champagne (2014), safety vests, posted signs, highlighted decorative aprons, and sashes have been used to reduce work interruptions. The project leader decided to incorpo- rate situation awareness (SA) with the use of a medication safety vest and

signage on the nursing unit and within patient rooms (“Do Not Disturb the Nurse during Medicat – ion Admini stration”). SA refers to a practitioner’s conscious awareness of a circumstance or situation (Stub – bings, Cha boyer, & McMurray, 2012). An educational in-service reinforced the purpose and rationale for the project.

Program The project leader, a student in a

Doctor of Nursing Practice (DNP) program, was interested in develop- ing a capstone project for continu- ous quality improvement (CQI). She requested a meeting with the chief nursing officer (CNO) and unit nurse manager to address the observed clinical problem. The CNO encouraged pursuit of this CQI opportunity. Project planning began after the project leader received approval from the facility administrator.

Clinical nurses on the unit were advised of the project 3 months before its initiation through com- munication during staff meetings. The project leader attended meet- ings the day before the launch to provide education regarding project implementation, including creation of SA, use of the medication safety

vest and signage, and completion of surveys about adherence to the no- interruption zone. According to Sitterding, Ebright, Broome, Patter – son, and Wuchner (2014), the need to understand interruptions with medication administration is neces- sary.

Disposable medication safety vests (Riskologic, LLC) were donat- ed to the project leader for use by the registered nurses (RNs) identi- fied as responsible for medication administration after the education- al session was completed. A vest labeled Do Not Disturb was used as a visual prompt to people who might approach nurses during medication administration. “Do Not Disturb the Nurse During Medication Administration” signage also was placed in medication preparation areas and all 28 patient rooms. Surveys regarding distractions, use of a medication safety vest and sig- nage, and evaluation of the project leader’s educational program were included.

MADOS Survey RNs completed a pretest/posttest

survey on types of distractions. The Medication Administration Dis trac – tion Observ ation Sheet (MADOS) identified 10 sources of distractions and interruptions (Pape, 2003).

Continuous Quality ImprovementContinuous Quality Improvement

Janet Tompkins McMahon

Work interruptions during medication administration are a serious problem negatively impacting patient safety. Using a medication safety vest and signage during medication administration improves situation awareness, reducing the potential for interruptions.

November-December 2017 • Vol. 26/No. 6 375

pleted and placed in a designated locked box on the nursing unit for the project leader’s collection. To ensure communication for the proj- ect, the anticipated time frame and overall project information were documented in minutes from the nursing unit meetings each time the project leader shared additional information. After completion of the 4-week project, the MADOS sur- vey was administered by the project leader to RNs on both 12-hour shifts. Those not present for the final meeting again were given the survey in their mailboxes with instructions to place completed sur- veys in the designated locked box located on the nursing unit.

Adherence Survey During the initial meeting about

the project, an adherence survey tool was introduced to RNs. The survey was a new tool developed by the project leader to evaluate previous adherence to use of the medication safety vest. The project leader’s DNP committee provided feedback re – garding content of the new tool before its initial use. The nurse unit had designated nursing leaders in place with resource nurses staffed on every 12-hour shift. Resource nurses (baccalaureate-prepared nurs es) were invited and encouraged to be cham- pions for the project. Champions evaluated medication safety vest use on 12-hour shifts daily by completing The Medication Safety Vest Compliance Report. Designated cham pions collected data every 12- hour shift each day for the project as requested by the project leader during orientation to the pilot study. The report listed percentage ratings (100%-90%, 89%-80%, 79%- 70%, 69%-60%, 59% and below) cor- responding to a grade of A, B, C, D, or E, respectively. Champions assigned a letter grade to RNs admin- istering medications to patients every 12 hours for the 4-week period. Completed daily reports were placed in designated locked boxes located in the areas identified on the nursing unit during the educational in-ser- vices at the nurses’ station.

Perceptions Survey A perceptions survey was dis-

cussed and reviewed during staff meetings, and administered after

Literature Summary • Cooper, Tupper, and Holm (2016) found 63% of medication passes

(n=30) were caused by interruptions during medication administration at a 271-bed Magnet® facility, resulting in decreased efficiency.

• Medication errors occur often within nursing practice compared to other types of errors (Tzeung, Yin, & Schneider, 2013).

• An integrative review by Hopkinson and Jennings (2013) found various interventions can be implemented to reduce work interruptions during medication administration, noting future research would be beneficial.

• Keers, Williams, Cooke, and Ashcroft (2013) found slips and lapses were common during medication administration. Other influences included written communication errors, perceived workload, and distractions and interruptions.

• Williams, King, Thompson, and Champagne (2014) found safety vests, posted signs, and use of highlighted decorative aprons and sashes reduced work interruptions during medication administration.

• According to Sitterding, Ebright, Broome, Patterson, and Wuchner (2014), a gap in knowledge and understanding of situation awareness exists during medication administration.

CQI Model Plan, Do, Check, and Act (PDCA) model (Russell, 2010)

Quality Indicator with Operational Definitions & Data Collection Methods • The number of medication errors on the unit was examined with data

extrapolated from the hospital medication variance reporting system. • The number of distractions was evaluated by the Medication

Administration Distraction Observation Sheet (MADOS). The MADOS identified 10 sources of distractions and interruptions (Pape, 2003). The MADOS was used pre- and post-project.

• Adherence to use of the medication safety vest was documented on the Medication Safety Vest Report each day during the 4-week project period.

• Effectiveness of the medication safety vest use, signage, educational ses- sions, and reference binder was evaluated after the project. A survey tool (Nurses Perceptions of the Medication Safety Vest, Signage, and Education Survey) also was used.

Clinical Setting 28-bed medical-surgical unit (average daily census 25-28 patients) in a 251- bed regional medical center

Program Objectives • Decrease number of medication errors on the designated nursing unit. • Create situation awareness to reduce distractions and medication errors

during medication administration with use of the medication safety vest and unit signage.

Examples in cluded telephone calls, interactions with patients and visi- tors, wrong dose, missing medica- tions, physicians, and external nois- es. The modified survey tool (used with permission from the publisher) identified nurses’ perceptions of the reasons and frequency of distrac- tions during the medication admin- istration. Nurses also were asked to identify the 10 most frequent dis- tractions (1=most frequent, 10=least frequent). This was ex plained to RNs

during the in-service by the project leader, and was reinforced on the MADOS form for RNs to see when following the directions. Descriptive statistics were used to examine these categorical data.

The MADOS survey (Pape, 2003) was provided to all RNs attending the educational meeting the day before the project began, and dis- tributed in RNs’ mailboxes for those not present at the meeting. These additional surveys were to be com-

Improving Medication Administration Safety in the Clinical Environment

November-December 2017 • Vol. 26/No. 6376

Continuous Quality Improvement

the 4-week project. The tool cap- tured RN perceptions of the medica- tion safety vest, signage, and educa- tional sessions. The survey was developed by the project leader with the assistance and feedback of content experts on the DNP com- mittee.

Evaluation and Action Plan Data from the Medication Var –

iance Reporting System (MVRS), which tracks medication errors in the hospital, were evaluated for 3 months before and 4 weeks after the project. Results of the MADOS surveys also were reviewed and ana- lyzed. Perceptions of medication safety vest and signage use, educa- tional session, and reference binder effectiveness were analyzed. Ad – herence to safety vest use was eval- uated as well. Project results were shared with the unit nurse manager and RNs as well as the CNO to begin discussions about potential change based on results.

Results and Limitations

Results MVRS results identified an 88%

decrease in medication error rates after implementation of the med- ication safety vest. Nine medication errors were reported by unit nurses 3 months before the project. Use of

the medication safety vest and sig- nage contributed to a clinically sig- nificant reduction to one medica- tion error during the 4-week project period. Importantly, the single error was related to a patient’s cardiac arrest when the safety vest was not in use.

Per MADOS survey results, exter- nal noises demonstrated a signifi- cant change (p=0.03). A two t-test was performed on the MADOS results because of the small sample size (see Figure 1).

Perceptions of the project were favorable (n=17). For 82% of RNs, signage in the patient rooms was always or often effective. Signage in the medication areas was always or often effective in 89% of cases. The medication safety vest was reviewed favorably 4% of the time. No nega- tive responses were recorded by RNs.

Adherence results for use of med- ication safety vests were above aver- age on both shifts (n=42). RNs used the medication safety vest 86% of the time over the 4-week period as evaluated by champions and the project leader. This result demon- strated above-average use of the medication safety vest during med- ication administration (see Figure 2).

Field Log Visits The random eight field log visits

by the project leader identified sub- jective feedback from nurses during the 4-week medication safety vest

use. Visits occurred on all shifts and on weekends. RNs stated they liked wearing the vest, and noted it worked. Some RNs admitted they would forget to use the vest during medication administration. Two RNs noted staff from other departments did not like the vest. They stated interprofessional team members expressed frustration when they could not interrupt the nurse during medication administration to re – trieve patient information. One RN indicated a patient’s family member asked for a safety vest for the use of her daughter (an RN at another hos- pital) because she thought it was a wonderful idea for patient safety. Two RNs did not want to stop wear- ing the vest after the project ended; they noted it worked in decreasing interruptions and helped them become more efficient.

Limitations Limitations included the sample

size (n=28), response time, and incomplete sets of MADOS surveys. A sample size should be greater than 30 when using central limit theorem to allow increased variabil- ity and distribution of results (Cooper & Schindler, 2003). In addition, results could have been affected if nurses changed behavior and wore the vest when the project leader made rounds for the observa- tion and field log. Finally, the tele- phone was a potential distraction

FIGURE 1. The Frequency of Distractions Ranked on 1-10 Scale Pre/Post Pilot Survey

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MADOS Survey Before Vest After Vest

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Improving Medication Administration Safety in the Clinical Environment

during the 4-week project time. Because nurses were required to carry a phone at all times, this dis- traction could not be eliminated; MADOS results identified it as the primary distraction.

Lessons Learned/ Nursing Implications

The timeline to begin and fore- cast a project may not be as easy as it appears initially. The project required a forecasted timeline months in advance to plan the proj- ect adequately and communicate needs with staff at the acute care facility. Any project or quality improvement study requires critical thinking and careful judgment by the project leader. Institutions have their own schedules and needs which come first, sometimes requir- ing reorganization of anticipated needs to another time or day. Meetings can be cancelled and may not be the priority for facility staff. Schedules may not match, creating a longer window of anticipation for implementation. The experience can be improved with enhanced knowledge and communication of medication error, rationale, types of distractions, and need for practice changes to improve outcomes with interprofessional efforts.

The biggest lesson from the proj- ect involved the need for communi- cation with all stakeholders to

ensure success. The project leader must be a strong communicator and organizer. The project required continuous monitoring as well as written and in-person communica- tion. Accountability with project expectations also is paramount for success. Use of effective communi- cation methods for participants reduces knowledge gaps to allow the project to proceed as planned.

In addition, the project leader must be flexible and willing to make changes with timelines. Not everyone shares the same passion for meeting project goals. Institut – ional priorities may not be the proj- ect leader’s priorities, so flexibility with planning and organizational forecasting is critical.

Such a project can guide nurse practice changes to im prove patient safety outcomes and reduce medica- tion errors. The SA created through use of the safety vest contributed to reduced distractions and medication errors. With reduced distractions while wearing the medication safety vest, RNs could focus more closely on administering medications. In addition, the interprofessional team became more independent in ob – taining information about pa tients without interrupting medication administration. Further investiga- tion or replication of the project would be beneficial to the nursing profession and for patient safety outcomes.

A positive change in RNs’ behav- ior included their request to contin- ue to use the medication safety vests after the project. RNs identi- fied a desire to address a policy change for using the vest during medication administration to con- tinue the reduction of potential medication errors from less distrac- tions on the unit by members of the healthcare team, patients, and fam- ilies. Signage used in conjunction with the medication safety vests and SA appeared to be effective as unit staff asked to keep all signage in patient rooms and medication administration area. To date, “Do Not Disturb the Nurse during Medication Administration” sig- nage still is used on the unit at the regional medical center.

Conclusion The CQI project demonstrated an

evidence-based solution to reduce errors and improve patient safety with medication administration. Medication errors decreased during the 4 weeks of the project while nurses wore the safety vest, and with placement of signage on the nursing unit in patient care areas during medication administration. Use of medication safety vests and signage is a potential solution for reducing errors and distractions during med- ication administration. Creating SA among nurses, other healthcare pro- fessionals, patients, and families using a medication safety vest, sig- nage, and education is vital for qual- ity improvement. Reduction of medication errors and distractions for nurses during a critical skill inter- vention with patient care is advan- tageous.

REFERENCES Cooper, D.R., & Schindler, P.S. (2003).

Business research methods (8th ed.). New York, NY: McGraw-Hill/Irwin.

Cooper, C.H., Tupper, R., & Holm, K. (2016). Interruptions during medication adminis- tration: A descriptive study. MEDSURG Nursing, 25(3), 186-191.

Hopkinson, S.G., & Jennings, B.M. (2013). Interruptions during nurses’ work: A state-of-the-science review. Research in Nursing and Health, 36(1), 38-53. doi: 10.1002.nur21515

continued on page 409

FIGURE 2. Adherence

50 45 40 35 30 25 20 15 10 5 0

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A (90-100)

B (89-80)

C (79-70)

D (69-60)

E (≤59)

Adherence Grades

45% 41%

7% 2%

5%

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Improving Medication Administration continued from page 377

Karavasiliadou, S., & Athanasakis, E. (2014). An inside look into the factors contributing to medication errors in clinical nursing practice. Health Science Journal, 8(1), 32-40.

Keers, R.N., Williams, S., Cooke, J., & Ashcroft, D.M. (2013). Causes of medica- tion administration errors in hospitals: A systematic review of quantitative and qualitative evidence. Drug Safety, 36(1), 1045-1067. doi:10.1007/s40264-013- 0090-2

Pape, T.M. (2003). Applying airline safety prac- tices to medication administration. MED- SURG Nursing, 12(2), 77-94.

Russell, C.L. (2010). A clinical nurse specialist- led intervention to enhance medication adherence using the plan-do-check-act cycle for continuous self-improvement. Clinical Nurse Specialist, 24(2), 69-75.

Sitterding, M.C., Ebright, P., Broome, M., Patterson, E.S., & Wuchner, S. (2014). Situation awareness and interruption han- dling during medication administration. Western Journal of Nursing Research, 36(7), 891-916. doi:10.1177 /019394591 4533426

Stubbings, L., Chaboyer, W., & McMurray, A. (2012). Nurses’ use of situation aware- ness in decision-making: An integrative review. Journal of Advanced Nursing, 68(7), 1443-1453. doi:10.1111/j.1365- 2648.2012.05989.x

Tzeung, H.M., Yin, C.Y., & Schneider, T.E. (2013). Medication error-related issues in nursing practice. MEDSURG Nursing, 22(1), 13-16, 50.

Williams, T., King, M.W., Thompson, J.A., & Champagne, M.T. (2014). Implementing evidence-based medication safety inter- ventions on a progressive care unit. American Journal of Nursing, 114(11), 53-62. doi:10.1097/01.NAJ.0000456433. 073 43.7f

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