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Reducing medication interruptions on a progressive care unit

Foody, Courtney, MSN, RN, PCCN; McDonald, Daniel, BS, AAS, RN; Lozano, Leo, BSN, RN, PCCN

doi: 10.1097/01.CCN.0000554837.72036.49
Department: Innovations
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Courtney Foody is an advanced nurse clinician at Virtua Memorial Hospital, Mount Holly, N.J.

Daniel McDonald is a clinical nurse at Virtua Memorial Hospital, Mount Holly, N.J.

Leo Lozano is a clinical nurse at Virtua Memorial Hospital, Mount Holly, N.J.

The authors have disclosed no financial relationships related to this article.

Medication errors are a leading, yet preventable, cause of patient harm. Healthcare providers need to make the medication administration process as safe as possible to reduce adverse drug events (ADEs), which include medication errors as well as near-misses. Medication errors are defined as medication administration at the incorrect time, frequency, strength, or dose; by the incorrect route; or to the incorrect patient.1 A near-miss can be defined as a risk of a medication error that is discovered before the error reaches the patient.2

Challenges arise when healthcare professionals must administer multiple medications to several patients, which can be complicated when confronted with a vast array of outside factors and interruptions. The original five rights of medication administration include the following: Right Patient, Right Medication, Right Dose, Right Route, and Right Time. These rights are often neglected when interruptions occur during a medication pass.3 Evidence reveals that millions of medical errors occur each year; 250,000 of these errors are directly related to medication errors, causing 44,000 to 98,000 deaths per year.4

The authors of the present study endeavored to reduce interruptions during a medication pass to ultimately decrease the number of errors and near-misses on the 31-bed progressive care unit in a community-based hospital. The nurses' schedules and assignments were random and followed a 4:1 patient-to-nurse ratio. The study began in November 2017 and concluded in August 2018. The purpose of the study was to reduce the number of interruptions during medication administration by 50% by the end of February 2018. This goal was achieved.

Preliminary data collection revealed that nurses were being interrupted on average 30 times during medication passes prior to any interventions being implemented. The nursing educator and staff sought answers to two questions. Is it possible to reduce the amount of medication interruptions? And, will reducing the amount of interruptions during a medication pass reduce the overall amount of medication errors?

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Methods

The study was conducted on the 31-bed progressive care unit of a community hospital in New Jersey. Seventy-three employees work on the unit regularly. No ethical issues were noted during the duration of the study. This was a quality improvement project supported by research; a random cluster experimental design showed correlation between medication interruption and ADEs.

The study was implemented when unit nurses expressed interest in wanting to ensure the safety of their patients during medication passes. The nurses used a tracking form to gather raw data regarding medication pass interruptions for 3 months during this study. The study began with the staff collecting primarily data followed by additional phases that included education. (See Interruptions tracking form.)

Nurses were initially educated on how to define a medication pass for this study. The study defined a medication pass as beginning when the nurse entered the medication room to remove medication from the dispensing machine, continuing through when the nurse left the medication room and entered the patient's room, and ended after the nurse administered the medication and completed related charting. Before the study interventions were implemented, the number of medication pass interruptions were tracked for 3 months. Interventions were then introduced in three waves, each tracked for 4 weeks.

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Intervention 1

In the first intervention of the study, the nurses were provided a stop sign image to place outside the patient's door to notify others that a medication pass was occurring and not to interrupt (see Do not disturb stop sign). Unlicensed assistive personnel (UAP) were also educated on the no-interruption medication pass intervention. The UAP began carrying phones to allow other staff members to contact the patient's UAP for common questions, such as how does the patient transport? By having the UAP carry phones, the number of calls that nurses received was decreased during the study.

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Intervention 2

The second intervention of the study consisted of the nursing educator presenting at ancillary departmental staff meetings, such as the transport, lab, telemetry, and pharmacy departments, to raise awareness of the no-interruption medication pass intervention and to develop improved ways of communicating with each other. For example, the staff now faxes the transport department a unit census with the patients' mode of travel daily. The telemetry unit now has all UAP phone numbers to reduce phone calls made to nurses. The lab and pharmacy departments were made aware of the project and were provided with education related to nurses not being interrupted during a medication pass. The lab and pharmacy staff were able to communicate with any nurse on the unit or could leave a message with the unit clerk. The unit clerk was provided specific education on how to triage phone calls and face-to-face needs. During a critical event, the nurse was interrupted immediately, otherwise the unit clerk waited until the medication pass was completed to interrupt the nurse. (See Interruption triage system.)

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Intervention 3

The third intervention consisted of the nurses wearing a small stop sign on their scrub top to prevent interruptions as they walked from the medication room to the patient's room along with the previous interventions being maintained. The nurses were able to point to the stop sign and continue to the patient's room without interruption. The nurses informed the unit clerk that a medication pass was being started; nurses also had the option to place their phones with the unit clerk. The unit clerk was also provided a formal message pad to record specific call details such as time, name of the caller, call-back number, and notes as a consistent way to take messages for nurses without creating new interruptions.

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Results

The study showed a direct correlation between reducing the number of interruptions and the decrease in the number of ADEs during a medication pass. Having the ability to track each phase during the project in real time showed that each phase reduced interruptions and reduced ADEs (see Study results).

In the 3 months prior to the interventions of the project being implemented (Phase 1), there were 1,446 interruptions and 60 near-misses. During Phase 2 of the study, interruptions were decreased to 189 and 3 near-misses with only the unit clerk triaging the phone calls. In the 3 months after implementing all the interventions (Phase 3), interruptions decreased to 96 with 0 near-misses. No medication errors occurred during the study. Overall, the unit was able to reduce interruptions by 93% and adverse events by 100%.

Overall, staff were satisfied with the outcomes associated with the project. Staff stated that having fewer interruptions allowed the nurses to focus on patients and their medications. Patients also stated that the nurses appeared more focused during a medication pass than they would have if they had been multitasking.

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Discussion

Postimplementation of the study suggested reducing interruptions during a medication pass decreases errors from occurring while increasing patient satisfaction. The nursing staff involved in the study said they had increased their focus during medication pass. The ancillary departments' involvement in the study was a key to success. Collaboration between nursing and ancillary staff made reducing interruptions during medication pass feasible. The expectations of decreases in ADEs with the reduction of interruptions by the researchers were met. When an ADE occurs on a progressive care unit, patient morbidity and mortality increases substantially.3 Decreasing interruptions during medication passes ensures patient safety is sustained.

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Limitations

Although the study was successful, there were limitations. Quasi-experimental design was the appropriate approach in establishing correlations between variables increasing internal validity and reliability of the study. Nurses were randomly scheduled to work on the unit; patients were assigned to the unit based on the severity of their care needs. The study was submitted to the hospital's institutional review board and approved. The study was limited to one unit in the hospital, so the external validity of the study cannot be concluded. Future studies with similar purpose should be conducted in different hospitals and different units. The nurses tallied their own interruptions for each medication pass, which allowed for nurse response/reporting bias to influence the outcomes of the study. The possible bias can be eliminated in future studies if results are tallied by independent staff. The nurses had to include their near-misses on their interruption sheet, which was turned in anonymously with only a date and information about ADEs and near-misses on the form.

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Conclusion

Reducing interruptions during a medication pass increases patient and employee satisfaction while reducing the potential for patient harm. There is a direct correlation between reducing interruptions during a medication pass and reducing ADEs. Ensuring patient safety and avoiding medical errors are goals for all healthcare providers. Understanding the process for a nurse when administering medication is essential to minimizing medication errors.5

Technology advances such as portable phones in healthcare delivery can lead to greater risk of medication administration errors, and more research is needed on this topic.6 No-interruption medication administration can improve patient safety; errors in medication administration are associated with higher mortality and morbidity rates.7 The structures and processes to prevent harm to patients must be grounded in evidence-based practice but must also remain practical enough for nurses to include in their daily workflows.

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REFERENCES

1. Hines S, Kynoch K, Khalil H. Effectiveness of interventions to prevent medication errors: an umbrella systematic review protocol. JBI Database System Rev Implement Rep. 2018;16(2):291–296.
2. Claffey C. Near-miss medication errors provide a wake-up call. Nursing. 2018;48(1):53–55.
3. Martins AC, Giordani F, Rozenfeld S. Adverse drug events among adult inpatients: a meta-analysis of observational studies. J Clin Pharm Ther. 2014;39(6):609–620.
4. Ohta Y, Sakuma M, Koike K, Bates DW, Morimoto T. Influence of adverse drug events on morbidity and mortality in intensive care units: the JADE study. Int J Qual Health Care. 2014;26(6):573–578.
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7. Hammoudi BM, Ismaile S, Abu Yahya O. Factors associated with medication administration errors and why nurses fail to report them. Scand J Caring Sci. 2018;32(3):1038–1046.
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