Lighting the Way to Medication Safety: Reducing Interruptions During Medication Administration in CardioThoracic Surgery Purpose

• Nursing is the last line of defense against errors. • Nurses may not correlate the impact of interruptions on the potential for adverse outcomes. • Many nurses take pride in their ability to multitask and handle interruptions. • Medication error rates indicated an area for improvement.

• The purpose of this study was to decrease the number of interruptions thereby reducing the incidence of medication errors.

Regi Freeman, MSN, RN, CNS; Bethany Lee-Lehner, BSN, RN; Scott McKee, BSN, RN; & Jennifer Pesenecker, BSN, RN 4C Cardiothoracic Surgery Unit, University of Michigan, Ann Arbor, MI Methods

• An Observational study using a random sample of nurses administering medications to determine the number of interruptions pre and post implementation of interventions. • Utilization of a standardized data collection tool to audit the number of interruptions. • Reported medication errors were reviewed pre and post implementation.

Impetus for change

A bundle of safety interventions were implemented to reduce interruptions during medication administration: • Lighted lanyards worn by nursing while administering medications • Creation of a No Interruption Zone (NIZ) in the medication room • Electronic Medication Administration Record review during shift report • Scripting card to encourage dialogue between nursing staff and patients/family • Phone scripts for clerks to triage calls • Patient education via brochures and signs • Letters to stakeholders regarding initiatives

Background Results Obtained grant funding Planning Education Medication safety initiatives implemented The number of medication errors reported each month displays a downward trend since implementation.

Current literature describes significant adverse monetary and safety effects of medication errors in the inpatient hospital setting. Reasons medication errors occur: • Unit layout • Nurse fatigue • Knowledge deficits • Inexperienced staff • Overhead pages • Physician rounds • Monitor & pump alarms • Multidisciplinary interruptions • Nurse, patient, & family questions • Workload & nurse to patient ratios

Results

Pre-intervention observations:

• Interruptions averaged 3.29 times during medication administration.

• An average of 1.36 interruptions occurred during IV push medication administration. • Patients, nurses, and family were the top 3 causes of interruptions pre-interventions.

Post-intervention Observations:

• Interruptions average of 1.18 times during medication administration.

• An average of 1.25 interruptions occurred during IV push medication administration. • Patients, nurses, and pagers were the top 3 causes of interruptions post-interventions. 70 60 20 10 0 Pre Post 50 40 30 3,5 3 2,5 2 1,5 1 0,5 0 Patient 64 17 3.29

1,18

Interruptions During Medication Administration

N=59 N=47

Oral Medications IV Push Medication

1.36

N=14

Leading Types of Interruptions

RN 56 15 Family 40 0 N=4 1,25 Pager 12 6 Pre Post

Discussion & Conclusion

• • Implementing interventions can reduce the interruptions during medication administration.

Reducing interruptions may decrease the number of medications errors that occur and can improve medication safety.

• Continued education, reminders, and auditing will provide continuous medication safety improvement.

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