An Analysis of the Medication Administration Process: The Impact of InterruptionsDenise Anderson, BSN, RN; Ashley Currier, BSN, RN; Erika Elganzouri, MBA, MSN, RN; Ryan Inlow; Frances Vlasses, PhD, RN, NEA-BC

Northwestern Memorial HospitalChicago, IL

Abstract

Problem: Medication errors that result in patient harm are the leading cause of error-related inpatient deaths. One national study estimated that adverse drug events occurred in 3.1% of all U.S. hospital stays in 2004.1 Numerous regulatory, professional, and research organizations, have recognized the public health implications of medication errors and made the reduction of these errors part of their priority initiatives.2

The current medication administration process has been identified as inefficient and prone to error, requiring many work steps that cause workflow constraints and variation in practice. As a result, there is a greater risk for medication errors.

Goal: Identify potential factors in the medication administration process and practice affecting safety and accuracy. Recommend improvements, based on study data, to help provide a safer medication administration process.

Study Description: This was a descriptive observational design study that used time and motion methods to gather detailed information on the nursing medication administration process. 50 Registered Nurses from three different inpatient units: Medicine, Surgery and Oncology were consented for participation. 426 medication passes were observed; 910 meds were passed (average of 2.14 medications/pass). Each participant was observed and timed during the medication administration process; including during preparation, retrieval, administration and documentation. A descriptive analysis of nursing practice during this process was documented. Motion data was captured by mapping workflow and by using pedometers to track steps taken during the pass. Finally, interruptions and distractions encountered during the pass were categorically described and timed; the interruption was then appropriately assigned to the area in the process it occurred.

Data Analysis: Data from each pass was analyzed to determine: length of pass—in time and distance, characteristics of observed processes—quantifying variations, environmental impact on pass based on observed workflow, and description, frequency and length of interruptions occurring during the process of medication administration.

Results Conclusion

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4:48

Med Retrieval Med Administration Documentation

Avg Time by Step In Process

Unit 1 (Avg Time)

Unit 2 (Avg Time)

Unit 3 (Avg Time)Time of PassAverage medication pass lasts 8 minutes and 5 seconds:

Unit 1 – 9 Minutes, 3 SecondsUnit 2 – 6 Minutes, 37 SecondsUnit 3 – 9 Minutes, 26 Seconds

Steps During PassAverage of 141 steps per pass:

Unit 1 – 138 stepsUnit 2 – 109 stepsUnit 3 – 167 steps

Interruptions During Pass307 med passes (72%) contained at least one interruption

712 total interruptions = 1.67 interruptions/medication pass

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Unit 1 Unit 2 Unit 3 Total

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Med Administration

Documentation

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Unit 1 Unit 2 Unit 3

Interruption Type by Unit(% of Total)

Patient Care

Communication

Pharmacy

Supplies & Equipment

Technology

Personal Time

Based on study data, it can be concluded that:

• Variations exist in the processes of medication preparation, retrieval, administration, and documentation among the Registered Nurses observed in this study.

• Interruptions impact the medication pass.

•The impact of interruptions varies based on type, time, and frequency of interruption, as well as, where the interruption occurs during the process.

• The majority of interruptions occur during the administration phase with patient care interruptions occurring most often.

• The incidence of interruption types varies by unit, however there are some notable similarities of commonly occurring interruptions among all study units.

•The number of interruptions that occur during a given pass is associated with a longer medication pass.

•RNs observed on Study Unit 3 took more steps per medication pass; this may or may not be affected by the differences in environmental design from the other study units.

• RNs observed on Study Unit 3 experienced a greater number of communication interruptions; this may or may not be affected by the differences in communication device and process from other study units.

Based on a thorough review of the literature and a comprehensive analysis of the study data, evidence-based suggestions for improvements to the medication administration process will be made. The implications for practice include, but are not limited to, a safer medication administration process and potential general process and systems applicability for other areas and institutions.

Next Steps

ReferencesTeam Members

Carol Payson, RN, MSN, NE-BC; Michelle Janney, RN, PhD, NEA-BC; Gary Fennessy; Tim Zoph; Rick Jacobson, B.S.Pharm, MBA; Katie DeJuras, RN, MSN; Ida Androwich, PhD, RN, BC, FAAN; Cherileen Niemiec, RN; Charisse Bedrejo, RN; Rebecca Schuetz, RN; Daniel Fraczkowski, RN; Katie Houser, RN; Elizabeth Tadina, RN; Daisy Abraham, RN; Andrew Bresnahan, RN

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1. Sakorski, J., Newman, J., & Dozier, D. (2008). Severity of medication administration errors detected by a bar-code administration system. American Society of Health-System Pharmacy, 65, 1661-1666.2. Joint Commission. 2008 National Patient Safety Goals—hospital program. www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm (accessed 2008 May 20).

Study Summary50 Registered Nurses participated in study

Observations performed on 3 nursing units (Medicine, Surgery, Oncology), 24 hours/day, 3 day period426 medication passes were observed; 910 medications were passed (average of 2.14 medications/pass)

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Interruption

Frequency of Interruptions by Type

Average Time and Instances by Interruption Type

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0:28

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Number of Instances

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1b - Isolation

2e – Staff (FYI)

1a – Family/Pt ?

1d – Pt. turned/changed/cleaned up

3a – Missing Med

1h – Non-assigned pt care

2b – Paged (call back)

2a- Paged (FYI)

5e – Nutrition Item for med

1c – pt requesting med (PRN)

2f Staff (requires attention)

1f – Restart IV

4b – Computer slow

5b – Missing supply

3d – Wait in line

2c – Paged (attention)

Other

1j – Nutrition Item (not for med)

Average Time and Instances by Interruption Type

0:00

0:28

0:57

1:26

1:55

2:24

2:52

3:21

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Number of Instances

Avera

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1b - Isolation

2e – Staff (FYI)

1a – Family/Pt ?

1d – Pt. turned/changed/cleaned up

3a – Missing Med

1h – Non-assigned pt care

2b – Paged (call back)

2a- Paged (FYI)

5e – Nutrition Item for med

1c – pt requesting med (PRN)

2f Staff (requires attention)

1f – Restart IV

4b – Computer slow

5b – Missing supply

3d – Wait in line

2c – Paged (attention)

Other

1j – Nutrition Item (not for med)