1. Methods Results Purpose Background Results
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, MI
Methods
Results
Purpose
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
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.
Impetus for
change
Obtained grant funding
Medication safety initiatives implemented
Education
Planning
Background
The number of medication errors reported each month displays a downward trend since implementation.
Results
Discussion & Conclusion
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
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 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.
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.
References
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Nguyen, E. E., Connolly, P. M., Wong, V. (2010). Medication safety initiative in reducing medication errors. Journal of Nursing Care Quality, 25(3),
 Trbovich, P., Prakash, V., Stewart, J. et al. (2010). Interruptions during the delivery of high-risk medications. The Journal of Nursing Administration, 40(5),