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Department: Evidence-Based Nursing

Stop "knowledge creep"

Pape, Tera (Theresa) PhD, RN, CNOR; Richards, Becky MA, BSN, RN

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Nursing Management (Springhouse): February 2010 - Volume 41 - Issue 2 - p 8-11
doi: 10.1097/01.NUMA.0000368559.85028.e3
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Medical centers across the world continue to struggle with safe medication administration. According to the Institute of Medicine, 26% to 38% of medication errors occur during the medication administration process.1 Research has demonstrated significantly successful approaches to reduce medication errors, yet there are still those who think that a proven idea will automatically spread rapidly into the practice setting without much effort. This usually doesn't happen and certainly not without a concerted plan. The focus today needs to be on reducing "knowledge creep"—in which nurses gradually begin to see the need to change practices based on limited research and by word of mouth—by utilizing more evidence-based research that's demonstrated its effectiveness, closing the gap between available research and clinical nursing practice, and understanding planned change.2

The spread of innovation depends on how it's communicated. The rate of adoption of the new strategy depends on whether the innovation is perceived as better than the past situation, the degree to which it's compatible with the current values and needs of potential adopters, whether the innovation is easy to understand and use, whether there's a feeling of uncertainty in trying a new experience, and whether the results of the innovation will be readily seen by the adopters.3 Innovative strategies should be recognized and encouraged and creative new methods rewarded and supported. An organizational climate that clears the way for innovation to be better communicated will be the one to improve practice settings. Remember, consumers support innovative practices when they can see the significant improvement that the practice makes.4

Collaborative efforts between nurse researchers and practice leaders can and do make a quality difference in reducing medication errors and improving nursing practice, as shown by the evidence-based practice journey of moving from research to practice implementation at a large healthcare system.

The problem surfaces

In 2006, after serious medication errors within a large healthcare organization, a comprehensive high-alert medication process (HAMP) was launched.5 The administrative team wanted to take the HAMP to the next level to lower the risk of all medication errors by changing the medication processes. The Risk and Patient Safety director located an article that would prove useful in this process, and shared this with the Adult Clinical Services director (ACSD). The noted research article described how distractions and interruptions continue to be major factors in medication errors. Because the nursing unit is especially vulnerable to a multitude of interruptions and distractions that affect memory and focus, nurses wore a special vest to indicate that interruptions weren't acceptable during medication administration. With the use of the vest, distractions and interruptions were significantly reduced.

The ACSD involved frontline nursing staff and the Quality Forum (QF)—a representative group of nurses from each area within the medical center with the purpose of addressing patient and nursing quality issues—to determine how best to implement this change. Based on medication error data and variance reports, the QF determined that distractions and interruptions were significantly affecting nurses' medication delivery. One of these distractions was identified as the use of a system in which the nurse carries a cell phone and is notified of any patient or physician need at any time. Although not all medication errors are caused by distractions and interruptions, this process needed to be addressed as part of the change in practice.

Innovative practices

Nurses at the healthcare organization began using a special vest during medication administration as a strategy to reduce interruptions and decrease medication errors. The nurses avoided conversation, and staff members reduced noise during all phases of medication administration. Nurses and staff members were educated about the new process and signage was posted on unit walls to improve awareness of the rationale for the practice.

Over a 19-day period, the number of distractions and medication errors was measured. Observations of nurses were conducted by five different individuals. Observers remained within 5 to 20 feet of nurses. The observations were then repeated in another unit that was structurally different. At first, the vests were flimsy and bright orange; nurses were very resistant to wearing them, so much so that the idea was almost dismissed as a bad idea. But when the results demonstrated such a significant reduction in medication errors, the decision was made to change the vests to a different style.

Medication errors were tracked by the Quality department and relayed to the ACSD. The primary variables measured included compliance with the protocol, rate of medication errors, and number of distractions. These quality improvement studies, which included all shifts and nurses, were conducted in 2006 in two different nursing units. The pilot study began in July in one unit and in September in the other unit. When compared with the first 6 months in 2006, there was a 47% decrease in medication errors, which was also sustained over the next 6 months. (See Figure 1.)

Figure 1
Figure 1:
Average number of medication administration errors per month

In 2007 during the third quarter, the only nurses interrupted or distracted were those who failed to wear the vest. Of those nurses (N = 7), interruptions and distractions occurred 43% of the time. Subsequently, a hospital-wide rollout began in April 2007, which provided a 20% decrease in medication administration errors in May 2007. There was only one unit in which errors increased instead of decreased because the unit was resistant to wearing the vests. (See Figure 2.) Data from one year to the next demonstrated a 60% reduction in errors in January 2008 when compared with January 2007, before the implementation of the medication vest.

Figure 2
Figure 2:
Average number of medication errors before vs. after implementation by unit

In addition, in January 2008 there was a 50% decrease in medication administration errors in spite of an increase in hospital census of 8%. Nevertheless, nurses saved time, as evidenced by a 20% time reduction per medication pass. A medication pass is described as the entire number of medications a nurse needs to administer at a specific scheduled medication time; for example at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. There was also a 17% increase in the number of medication passes that fell within the "on-time" window (±60 minutes).

In 2008, the practice was adopted by all Kaiser Hospitals in California, Oregon, and Hawaii, with plans to roll out nationally by the end of 2009. Results continue to be promising as the innovation spreads. This has made a dramatic and positive difference for the healthcare organization's patients, nursing staff, and administrative leaders. After more than a year of work, the administration knew it was time to contact the author of the original idea and seek suggestions and support for the future.

Making the connection; disseminating information

Contact was made by the ACSD, and a new alliance began with the nurse researcher. Not only was the researcher receptive, but her openness to the work being done at the healthcare organization took both parties to new levels. Early in the collaboration, it was evident that both parties demonstrated interest in and commitment to sharing works and efforts for the same goal—to ensure patient safety through safe medication administration and improve the working conditions for nurses. For example, the CalNOC distraction measurement tool was combined with the original study instrument—the Medication Administration Distraction Observation Sheet—to improve the measurement of nurses' distractions during medication administration. Both parties continued to make references to each other's work, maintaining frequent contact in order to smooth the process and share the publicity and success of these efforts and to support and encourage each other.

In May 2007, a member of the Kaiser Innovation group contacted the ACSD and shared information. The center's director has furthered the work by assisting with the development of a sash to be worn instead of the vest. Thus, the nurses have a choice of wearing a vest or a sash to indicate to others not to interrupt them. The sash has been further improved to have a single snap on one side.

Further refining of what's now referred to as the KP Med Rite process has also occurred. The protocol is now made up of three components:

  • Process: The step-by-step process nurses should use to administer medications. (As with the original study, it represents the way nurses were taught to deliver medications.)
  • No interruption wear: A sash or vest is worn to signal that no one should interrupt (talk to) the nurse who's wearing it unless there's an emergency.
  • Safety zone: A space is marked out on the floor with red tape or red tiles in front of the area where the nurse pulls and prepares medications in the medication room. No one is to cross into the space or talk to a nurse who's in the zone.

Conclusion and recommendations

Working together and sharing information has brought this innovation to a higher level and with more credibility than before, proving that broader audiences can be reached through collaboration and demonstrating that furthering the sharing of information related to this approach to safe medication administration can be applied to many other types of work and should be encouraged. Medication administration errors at the healthcare organization continue to decline due to this innovation.

The world of healthcare is becoming smaller in distance due to technology. It might seem risky to share work with a complete stranger, but remember that nurses are generally open to others and disseminating knowledge helps reduce knowledge creep. The continued reduction of medication administration errors due to the innovation described in this article is certainly a vivid demonstration of this. Hopefully others will be encouraged to try collaboration, leading to enhanced individual and group efforts.


1. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; 2007.
2. Pape TM. Evidence-based nursing practice: to infinity and beyond. J Contin Educ Nurs. 2003;34(4):154–161.
3. Rogers E. Diffusion of Innovations. 5th ed. New York, NY: Free Press; 2003.
4. Coonan PR. Educational innovation: nursing's leadership challenge. Nurs Econ. 2008;26(2):117–121.
5. Pape TM. Applying airline safety practices to medication administration. Medsurg Nurs. 2003;12(2):77–93.
© 2010 by Lippincott Williams & Wilkins, Inc.