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Implementing Evidence-Based Medication Safety Interventions on a Progressive Care Unit

Williams, Tyeasha DNP, APRN, FNP-C; King, Melissa W. PharmD, BS; Thompson, Julie A. PhD; Champagne, Mary T. PhD, RN, FAAN

AJN, American Journal of Nursing: November 2014 - Volume 114 - Issue 11 - p 53–62
doi: 10.1097/01.NAJ.0000456433.07343.7f
Cultivating Quality

Overview While preparing medications in complex health care environments, nurses are frequently distracted or interrupted, which can lead to medication errors that may adversely affect patient outcomes. This pilot quality improvement project, which took place in a 32-bed surgical progressive care unit in an academic medical center, implemented five medication safety interventions designed to decrease distractions and interruptions during medication preparation: nursing staff education, use of a medication safety vest, delineation of a no-interruption zone, signage, and a card instructing nurses how to respond to interruptions. Four types of distractions and interruptions decreased significantly between the two-month preimplementation and two-month postimplementation periods: those caused by a physician, NP, or physician assistant; those caused by other personnel; phone calls and pages placed or received by the nurse during medication administration; and conversation unrelated to medication administration that involved the nurse or loud nearby conversation that distracted the nurse. The total number of reported adverse drug events also decreased from 10 to four, or by 60%. Thus, medication safety interventions may help decrease distractions and interruptions in high-acuity settings.

How nursing staff at one facility implemented five medication safety interventions designed to decrease distractions and interruptions during medication preparation.

Tyeasha Williams is a part-time staff nurse at Duke University Medical Center, Durham, NC, and an NP at a CVS Minute Clinic in Burlington, NC. Melissa W. King is the medication safety manager at Duke University Medical Center. Julie A. Thompson is a consulting associate/statistician in the Duke University School of Nursing, and Mary T. Champagne is the Laurel Chadwick Distinguished Professor of Nursing in the Duke University School of Nursing and professor in the Department of Community and Family Medicine at the Duke University School of Medicine. Contact author: Tyeasha Williams, tyeasha.williams@dm.duke.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.

© 2014 Lippincott Williams & Wilkins. All rights reserved.