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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. 137 138 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- 139 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 140 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 142 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2010 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%. 143 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 144 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. REFERENCES 1. Lassetter J, Warnick M. Medical errors, drug related problems, and medication errors: a literature review on quality of care and cost issues. J Nurs Care Qual. 2003;18(3):175–181. 2. Schelbred A, Nord R. 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