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J Nurs Care Qual
Vol. 25, No. 2, pp. 137–144
c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright Medication Room Madness
Calming the Chaos
Carole Conrad, RN; Willa Fields, DNSc, RN, FHIMSS;
Tracey McNamara, BSN, RN; Maryann Cone, MSN, RN;
Patricia Atkins, MS, RN
Nurses work in stressful environments, encountering interruptions and distractions at almost every turn. The aim of this medication safety project was to improve the physical design and organizational layout of the medication room, reduce nurse interruptions and distractions, and create a
standard medication process for enhanced patient safety and efficiency. This successful change improved the medication administration process, decreased medication errors, and enhanced nursing
satisfaction. Key words: medication errors, outcomes and process assessment, patient safety,
performance improvement
M
EDICATION administration errors are a
major challenge for hospitals, clinicians,
and patients. Medication errors have the potential to cause patient injury, staff distress,
and increased hospital costs that include a
longer length of stay, patient complications,
and legal expenses.1,2 Medication errors are
often the result of system failures. Contributing factors include insufficient training, inadequate systems and processes, ineffective communication, environmental challenges, and
the failure to adhere to standard protocols
during medication administration.3–5 The purpose of this medication safety project was
to improve the physical design and organizational layout of the medication room, reduce nurse interruptions and distractions, and
create a standard medication administration
process for enhanced efficiency and patient
safety.
Author Affiliations: Sharp Grossmont Hospital, La
Mesa, California (Mss Conrad, McNamara, Cone,
and Atkins); and San Diego State University and
Sharp HealthCare, San Diego, California (Dr Fields).
Corresponding Author: Carole Conrad, RN, 5555
Grossmont Center Dr, La Mesa, CA 91942 (Carole.
[email protected]).
Accepted for publication: October 1, 2009
BACKGROUND
Medication preparation and administration
are critical activities that require the nurses’
undivided attention. In our hospital, the clinical nurses complained of excessive interruptions and distractions during the medication
administration process. Also, supplies were
not organized and often missing, the pharmacy in-bin was too high to reach, there were
not enough bins for nonrefrigerated medications, and the access to bulk bins was awkward. Medication error data, retrieved from
the incident reporting system, revealed that
42% of reported medication errors occurred
during the administration phase whereas only
28% occurred during transcription and documentation, 15% during dispensing, and 14%
during prescribing.
Staff and management were committed
to improving the medication administration
environment and process. The goal of the
project was to enhance medication administration safety and efficiency by improving
the medication administration environment.
A project team was formed, which included
members from management, clinical nurses
from various departments, and staff consultants from central supply, pharmacy, and
information systems.
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JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2010
The project took place at Sharp Grossmont Hospital, San Diego County, California;
it is a 481-bed tertiary care, not-for-profit,
Magnet-designated community hospital.
Sharp Grossmont Hospital is part of the Sharp
HealthCare integrated regional healthcare
delivery system, which was named a recipient of the 2007 Malcolm Baldrige National
Quality Award. The medication safety project
was piloted on a 41-bed progressive care
unit, which has an average daily census of
35, an average length of stay of 4.1 days, and
approximately 8 discharges and admissions
per day. There are 2 medication rooms, 29
private rooms, and 6 semiprivate rooms in
the unit. The patient population is primarily
patients with cardiac, pulmonary, and renal
diseases. Patients receive an average of 19
scheduled medications with a range of 7 to
32 and an average of 10 PRN medications
with a range of 1 to 15 in a 24-hour period.
There are 72 registered nurses (RNs) with a
patient-to-nurse ratio of 4:1 during the day
and a 5:1 ratio during the night.
PERFORMANCE IMPROVEMENT
PROCESS
The project team used Lean Six Sigma,
a customer-focused, process improvement
method that uses data to make informed
decisions and reduce unnecessary variation to
improve workflow and eliminate waste.6 Lean
is a methodology that focuses on the elimination of waste such as wasted motion and time
spent waiting. Six Sigma is a statistical term
that represents near-perfect levels of performance. Lean Six Sigma projects use DMAIC,
an improvement methodology with 5 phases:
define, measure, analyze, improve, and control (DMAIC).
Define (D)
Using the DMAIC phases, the project team
created a project charter that identified problems with the current medication administration process and defined the project scope
and customers served. The team identified 60
“Critical to Quality” elements for safe admin-
istration of medications. These elements involved multiple team members: the physician
writing a clear and complete order; the pharmacist interpreting the order, completing
a safety review of all medications on the
patient’s medication administration record,
checking for allergies and interactions,
and then making the medication available
in a timely manner; the nurse maintaining
current medication education and competencies, reviewing all physician medication
orders, assessing the patient, reviewing
pertinent patient laboratory values for
appropriateness of the medications, and administering and documenting the medication
in the patient’s chart; and the unit manager
providing a quiet and organized medication
room with adequate space, supplies, equipment, drug guides, guidelines, and education
tools with no unnecessary distractions.
The project scope was limited to the administration and documentation aspects of medication administration: from the time the nurse
was prompted to give a medication through
preparation, administration, and documentation. Prescribing, transcribing, and dispensing
medications were beyond the scope of this
project.
A review of the 60 elements accentuated
that safe medication administration required
nurses to focus their attention for complex
critical thinking and clinical judgment to
ensure positive patient outcomes and prevent harm. The initial problems that nurses
encountered during medication administration were defined as a lack of an organized,
well-supplied, and efficient medication
administration preparation area and multiple
distractions
and
interruptions
while
administering medications. Customers served
included physicians, pharmacists, pharmacy
technicians, central supply clerks, other
nurses, and patients. The primary customer
for this project was the nurse.
Measure (M)
Clinical nurses were surveyed about their
perceptions of the medication administration process before and after the project.
Medication Room Madness
The project team developed a 7-question
survey, using a 5-point Likert scale from
1 (strongly disagree) to 5 (strongly agree)
to rate statements about the efficiency of
the medication process, obstacles confronted,
distractions and interruptions, team support,
available resources, and performing mandatory double checks. At the end of the survey, respondents were asked to comment
on obstacles they experienced while administering medications. Other measurements
included direct observation of nurses administering medications and a review of existing
medication error data.
Project team members were trained in conducting time and motion observations by
an expert process improvement coach from
the healthcare system’s clinical effectiveness
department. The trained observers followed
nurses as they administered medications. The
observers timed the medication administration process with a stopwatch and tracked the
nurses’ activities throughout the unit on a paper diagram of the nursing unit. Interruptions
were also noted on an observation sheet.
Nichols et al4 demonstrated that many medication errors are due to attention slips that occur from being stressed, tired, and distracted
during the medication administration process. Eisenhauer et al7 reported that nurses
must have constant professional diligence during the medication administration process to
ensure that patients receive their appropriate medications. Observations of nurses while
preparing medications and inspection of the
medication room revealed that necessary supplies to prepare medications were stored in
an arbitrary manner without consideration to
the frequency they were used or the process in which they were needed. Nurses were
observed reaching over one another to get
items and having to wait to access supplies.
Nurses traveled to multiple locations within
the unit to acquire the necessary supplies for
a given medication administration. Furthermore, the nurses searched for medications
in up to 5 locations: the patient’s medication cassette, one or both of the medicationdispensing cabinets (eg, Pyxis), the refrigera-
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tor “in box,”and the nonrefrigerated “in box.”
Chaos ensued from the wasted motion, delays, distractions, and subsequent frustration.
It is well documented that nurses are interrupted frequently while preparing and administering medications.4,8–15 One observation revealed that a nurse had 11 interruptions while
going to multiple locations to obtain the patient’s medications and related supplies. For
example, while resupplying medication cups,
a visitor asked the nurse for water. When obtaining intravenous (IV) tubing in a separate
location, a physician asked the nurse to help
find the patient’s chart. While the nurse was
collecting IV tubing labels in another location,
a nurse asked for assistance in repositioning a
patient in bed. This particular medication administration took 20 minutes to complete and
exposed the nurse to multiple opportunities
for interruptions. Most importantly, these interruptions caused a fragmented process and
loss of concentration for critical thinking. The
occurrence of interruptions is often an accepted part of nurses’ work; however, there
is a need to eliminate these interruptions during the medication process.12
Other observations made during the
project revealed that the medication
administration process took between 7 and
20 minutes per patient with an average
time of 15 minutes. These observations confirmed a chaotic environment for medication
administration with multiple delays including
a need to clarify orders and correct inaccurate
information. Nurses also found it difficult
to access necessary laboratory information
because there was no computer in the medication room. The challenge for the team was
to identify ways to achieve a consistent, errorfree, and efficient medication administration
process as illustrated in Figure 1. Figure 2
illustrates the unit’s actual medication flow
map, complete with interruptions and delays.
Necessary interruptions were defined as
those interruptions that added value to patient care, customer service, or nurse satisfaction, and could not wait until after
medications were administered. Time to administer medications began when the nurse
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JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2010
Prompted to
give medications
Prepares medications
Identifies
patient
Interprets
MAR (5Rs)
Explains
medications
to patient
Performs
preadministration
assessment/
checks allergies
Prepares to
administer medications
(final 5Rs)
Washes
hands
Gives medications
Procures
med/IV &
supplies
(5Rs)
Evaluates effects
of medications
Washes
hands
Documents
medications
Figure 1. Medication administration flow map without interruptions (average time: 7 minutes). IV indicates intravenous.
Prompted to
give medications
Prepares
medications
Wait in line
Phone call
Phone call
Interprets
MAR (5Rs)
Performs
preadministration
assessment/
checks allergies
Washes
hands
Procures
med/IV &
supplies
(5Rs)
Questionable
order
Need to
clarify
Call MD;
Wait;
Get
clarification
Unexpected
task
Can not find
med; look in
4 places; call
pharmacy,
then find it
Identifies
patient
Explains
medication
to patient
Unexpected
task
Prepares to
administer
medications
(final 5Rs)
Locate missing
supply
Gives medications
Phone call
Washes
hands
Evaluates
effects of
medications
Documents
medications
Figure 2. Medication administration flow map with interruptions (average time: 20 minutes). IV indicates
intravenous.
Medication Room Madness
141
was prompted to administer a medication
and ended when the medication was documented.
patient nursing units to improve their medication administration room and process.
Analyze (A)
Two well-respected staff nurses on the
progressive care unit, passionate about medication safety, were chosen to lead the
medication room redesign. Previous research
identified a cluttered and disorganized medication room as a contributing factor for medication errors.3,8,10,11 The redesign started
by identifying the supplies and equipment
needed, determining a specific location for
each supply depending on how and when
it is used, and establishing the quantity required for a 24-hour period. Anything that
did not pertain to medication administration
was removed from the medication room, including signs, memos, and bulletins. The goal
was to organize the medication room for
efficient workflow, accessible supplies and
equipment, reduction in distractions, and improvement of ergonomic safety (Fig 3).
Supplies were arranged by category such as
IV administration, injections, glucose management, syringes, diluents, pill cutters/crushers,
and medication cups. For example, IV starter
kits, catheters, gauze pads, and extension tubing were stocked together. High-volume-use
items such as alcohol wipes and saline flushes
were located in easy-to-reach areas. Items
were placed with consideration to body mechanics and ergonomics; heavy IV solutions
were located at eye level for easy viewing of
labels and access without bending, kneeling,
or lifting. In addition, a charting station was
removed from the medication room because
it created a place where staff could socialize.
Nursing collaborated with central supply
on inventory and restocking. Central supply
usage reports were reviewed and updated
to improve supply management by determining a sufficient quantity for a 24-hour period.
Careful consideration was given to how items
were stored. Cabinets and drawers were replaced with open shelving with bins of varying widths to accommodate different-sized
items. Each bin had a “nurse friendly” label to
help quickly identify the bin contents and a
In the Analyze phase, the team used the
collected data and prioritized opportunities
for improvement. Medication safety reports
demonstrated that the highest percent of errors occurred during administration. Observations of nurses’ workflow during medication administration revealed delays from
answering phone calls, clarifying orders,
searching for medications and supplies, waiting to access medications, and performing unexpected tasks (Fig 2). Therefore, the team
focused improvement efforts on those activities that delayed or interrupted medication
administration and created practice guidelines for improved medication administration
safety.
Improve (I)
The team identified 5 improvement
strategies:
1. Create a standard environment for medication room design and processes.
2. Minimize unnecessary distractions and
interruptions during medication administration.
3. Develop a standard protocol for medication administration that includes checking for the “7Rs” (right patient, medication, route, dose, time, reason, and
documentation).
4. Establish mandatory double-check process for insulin, heparin, and warfarin.
5. Provide education on the medication
administration guideline, double-check
procedure, new medication administration environment, technology supports
in the automated medication dispensing
unit, and the electronic nursing documentation system.
The team directed the medication room redesign, implemented ways to decrease interruptions, improved existing policies and procedures, and created an implementation tool
kit to aid other Sharp Grossmont Hospital in-
Standard environment
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team collaborated with the managers of central supply and the unit manager to determine the best time to make changes to the
medication room. One medication room was
closed for 2 days while the cabinet doors were
removed, a patient computer station was
installed, the room was repainted, and new
carpet was installed. Move-in day took 3
hours: central supply delivered the approved
carts, and they worked with the redesign team
to stock the medication room.
Distractions
Figure 3. Before and after medication room photographs. Before the redesign, cabinets had doors
and contained random supplies. After the redesign,
all contents were organized and placed in labeled
bins.
central supply label with stocking information
to help with inventory control. For example,
a nurse-friendly IV label read “1/2 NS” while
the central supply label read “0.45 Sodium
Chloride.”
The nursing team also redesigned the supply carts. Central supply created mock-up
carts that nurses evaluated for workflow, accessibility, and staff safety. The inventory list
was organized so that the items appeared in
the order they were located in the cart. This
list supported keeping the items well-stocked
and in the correct location. It had been discovered that the central supply staff who
restocked the carts did not know how the supplies were used or that location in the cart was
important.
Care was taken not to disrupt patient care
while the changes were made. The redesign
Pape et al11 demonstrated that distractions during medication administration can be
reduced through signage and education. Creative signs were posted outside medication
room doors to encourage a quiet environment
during medication administration. Also, additional signs were posted inside the medication room to remind nurses to refrain from
having conversations while preparing medications. The chief nursing officer sent a
memo to all departments, requesting that only
urgent phone calls be placed to nurses between 8:30 and 10:00 AM and between 8:30
and 10:00 PM, the peak times for medication
administration. Nurses were provided sample
“scripts” to help handle interruptions during
medication administration, such as, “I would
like to be able to give you my full attention,
however, I am giving medications right now
and it really requires my full focus—could you
call back in ten minutes?” These changes promoted a calm, clinical environment that supported the safe administration of patient medications.
Standard protocol
Previously, nurses practiced the “5
Rights”—right patient, medication, route,
dose, and time—for medication administration. This guideline was expanded to include
the “7 Rights” and now includes the right
reason and documentation.
Mandatory double checks
The guidelines for administering insulin,
heparin, and warfarin were changed to
Medication Room Madness
incorporate independent “double check”
steps. A second nurse was given the medication order and pertinent laboratory values and
asked to independently verify the medication
dose. For example, in an insulin “double
check” the nurse tells a second nurse that the
patient’s blood glucose level is 150 mg/dL,
he had his dinner, and he ate well. The
second nurse verifies the insulin scale and
the appropriate insulin dose is correct.
Education
Staff were educated during staff meetings
and inservices about the need to maintain a
quiet environment without distractions while
administering medications, the change from
“5 Rights”to “7 Rights,”and mandatory double
checks for administering insulin, heparin, and
warfarin.
Control (C)
Once the changes were in place, control
was achieved through ongoing monitoring of
the medication room by a designated unit
nurse. Any additions or alterations to the
medication room environment are evaluated
by this nurse to ensure that any proposed
changes will not affect nurses during medication administration. Results from the nurse
surveys conducted after the project suggested
that the new medication process was viewed
as more efficient with less obstacles, distractions, and interruptions. The nurses reported
more adequate resources and team support,
although performance on double checks remained unchanged.
Unnecessary interruptions decreased from
a median of 4 interruptions before the project
to a median of 1 interruption per medication administration after the project was
completed. The time for medication administration also decreased from a median of
15 minutes (SD = 5.9) to a median of
10 minutes (SD = 4.7). There was no statistical difference pre- and postproject for the
number or route of medications. Reported
medication errors decreased 22% the first
year, and by the end of the third year the medication error rate decreased a total of 53%.
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SUCCESS FACTORS
Key success factors included the use of
Lean Six Sigma and DMAIC, expert process
improvement coaching and consultation,
chief nursing officer sponsorship, management and leadership support, collection of
pre- and postdata, clear project parameters,
prioritization of improvements, and specific
outcome measures for evaluation. Lean Six
Sigma and DMAIC provided the structure,
process, tools, and direction to organize and
focus improvement activities. The coach/
consultant was invaluable in guiding the
group through the use of the Lean Six Sigma
tools and methods. Without this methodology
and guidance, we would have been at risk for
a scattered improvement approach.
Management support extended from the
unit manager to the chief nurse officer and
chief executive officer. They viewed the staff
nurses working on the project as their customers and provided the necessary human
and financial resources to ensure a successful change. Management responded quickly
to requests and removed barriers so changes
were implemented without delay. Unit managers demonstrated their support by identifying 2 committed and respected staff members to lead the project, and then providing
them with release time to attend meetings
and make the recommended changes to the
medications rooms, policies, procedures, and
educational materials. The staff viewed management as supportive in helping them identify ways to improve the safety of medication administration structure, processes, and
equipment. The focus of this project was
to change the environment and process of
medication administration; everyone was focused on improving medication administration safety without blaming and identifying
individual performance issues.
Management identified clear parameters
for the redesign of the medication rooms;
the medication rooms could be altered and
changes needed to adhere to good ergonomic
design. The safety officer was consulted
on changes to ensure that staff safety was
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JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2010
not compromised and appropriate ergonomic
design was used to avoid bending, kneeling,
or lifting. The unit project leaders solicited
input from the unit’s nurses and encouraged
them to be creative and make suggestions. All
suggestions were considered, although not all
were implemented.
Nurses now realize change is possible. The
reported data exposed flaws in the system,
validated the need to change the environment, and gave the staff hope that their
problems and suggestions would be acted
upon. After changes were made, other units
in the hospital were motivated to make similar changes because it was apparent that
redesigning the medication room, developing strategies to decrease nurse interruptions, and changing medication policies and
procedures improved nurse efficiency and
patient safety. Nurses were more satisfied
with the ease of obtaining and administering
medications while patient care quality was
improved, as evidenced by a reduction
in medication administration errors. This
medication safety project demonstrated that
environmental and process improvements
can be achieved with leadership support,
empowered clinical nurses, and multidisciplinary teams, using a structured improvement processes such as Lean Six Sigma.
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