An Analysis of the Medication Administration Process: The Impact of Interruptions
Denise Anderson, BSN, RN; Ashley Currier, BSN, RN; Erika Elganzouri, MBA, MSN, RN; Ryan Inlow; Frances Vlasses, PhD, RN, NEA-BC
Northwestern Memorial Hospital
Chicago, IL
Abstract
Results
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
Steps During Pass
Average of 141 steps per pass:
Unit 1 – 138 steps
Unit 2 – 109 steps
Unit 3 – 167 steps
• Variations exist in the processes of medication
preparation, retrieval, administration, and
documentation among the Registered Nurses observed
in this study.
Avg Time by Step In Process
4:48
• Interruptions impact the medication pass.
4:45
4:39
3:36
•The impact of interruptions varies based on type, time,
and frequency of interruption, as well as, where the
interruption occurs during the process.
Unit 1 (Avg Time)
2:24
Time of Pass
Average medication pass lasts 8 minutes and 5 seconds:
Unit 1 – 9 Minutes, 3 Seconds
Unit 2 – 6 Minutes, 37 Seconds
Unit 3 – 9 Minutes, 26 Seconds
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.
2:33
2:23
Unit 2 (Avg Time)
2:07
2:00
1:40
Unit 3 (Avg Time)
1:38
1:12
0:00
Med Retrieval
Med Administration
• The majority of interruptions occur during the
administration phase with patient care interruptions
occurring most often.
Documentation
Interruptions During Pass
307 med passes (72%) contained at least one interruption
712 total interruptions = 1.67 interruptions/medication pass
Interruptions by Step In Process
(% of Total)
• The incidence of interruption types varies by unit,
however there are some notable similarities of
commonly occurring interruptions among all study units.
Interruption Type by Unit
(% of Total)
70.0%
•The number of interruptions that occur during a given
pass is associated with a longer medication pass.
50.0%
•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.
60.0%
40.0%
50.0%
40.0%
Med Administration
20.0%
Patient Care
Communication
30.0%
Med Retrieval
30.0%
Pharmacy
20.0%
Documentation
10.0%
Supplies & Equipment
Technology
10.0%
• 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.
Personal Time
0.0%
Unit 1
Unit 2
Unit 3
Total
0.0%
Unit 1
Unit
Number of Interruptions Effect on Average Time
(All Units)
Unit 2
Unit 3
Average Time and Instances by Interruption Type
3:21
30:00
1f – Restart IV
Next Steps
1d – Pt. turned/changed/cleaned up
2:52
2f Staff (requires attention)
24:00
1c – pt requesting med (PRN)
Average Time
Average Time
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.
Based on study data, it can be concluded that:
3:18
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.
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.
Conclusion
Study Summary
50 Registered Nurses participated in study
Observations performed on 3 nursing units (Medicine, Surgery, Oncology), 24 hours/day, 3 day period
426 medication passes were observed; 910 medications were passed (average of 2.14 medications/pass)
18:00
12:00
2:24
3a – Missing Med
1a – Family/Pt ?
1:55
Other
5e – Nutrition Item for med
4b – Computer slow
1:26
5b – Missing supply
3d – Wait in line
6:00
0:28
0:00
0
1
2
3
4
5
6
7
2e – Staff (FYI)
2c – Paged (attention)
0:57
1j – Nutrition Item
(not for med)
1h – Non-assigned pt care
2b – Paged (call back)
1b - Isolation
2a- Paged (FYI)
0:00
8
0
Number of Interruptions
10
20
30
40
50
Number of Instances
Frequency of Interruptions by Type
90
60
70
80
Based on a thorough review of the literature and a
comprehensive analysis of the study data, evidencebased 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.
80
Team Members
60
Frequency
Carol Payson, RN, MSN, NE-BC; Michelle Janney, RN, PhD, NEABC; 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
70
References
50
40
30
20
10
0
1b
1a
2 e
3 a
1d
2 b
2 a
1h
5e
1c
4 b
3 d
2 f
5b
2 c
4 a
1f
1j
2 d
Interruption
3h
1e
1i
3 c
5a
3 b
5g
3 f
3 g
1g
4e
4f
5c
6b
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.ht
m (accessed 2008 May 20).