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Project Title: *Medication Administration Error Reduction
Author/Clinician’s Name: Executive Sponsor
Sandra Kissoon, Chief Nursing Officer
Team Members
Meriam Nguyen, RN, MSN 2AB Med/Surg
Christine Ng, RN
Rita Mughannam,RN
Quality Management
ICU
Noreen Sol, RN 2AB Med/Surg
Cynthia Javines Delmo, RN, MSN 2AB Med/Surg
Organization:
James Mercado, RN 2AB Med/Surg
Lynda Sutherland, LVN 2AB Med/Surg
Josephine Masinsin, RN 2AB Med/Surg
Dennis Santos, RN 2AB Med/Surg
Gerard Cabarse, RN
Shiva Merat, RPh
San Mateo Medical Center
2AB Med/Surg
Pharmacy
Title: See above
Describe the motivation behind implementing this project.
For example, what gaps in practice are you trying to address?
Interruptions during medication administration on the participating units were shown to persist in the form of nurse to nurse non-medication interruptions, MD interrupting RN with questions, patient/family with non-urgent requests, phone calls from other units, medications that were not available in the Pyxis/med room, student RNs/clinical instructors and life/human nature.
The focus of this project was to reduce the incidence of medication administration errors by decreasing interruptions/distractions during medication pass hour, standardizing the medication administration process, and developing a sustainable model for change.
Describe the target population and problem at hand.
Patients admitted to inpatient units. This project targets patients on the Medical Surgical and
ICU units at San Mateo Medical Center, though could be implemented on any unit where interruptions are common during medication administration and current protocols are not successful.

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Describe the intervention and its purpose.
Are there alternative interventions that would be comparable?
Interruptions during medication administration on the participating units were shown to persist in the form of nurse to nurse non-medication interruptions, MD interrupting RN with questions, patient/family with non-urgent requests, phone calls from other units, medications that were not available in the Pyxis/med room, student RNs/clinical instructors and life/human nature.
This project designated a medication pass time from 8-9am for standardization purposes (see
attached San Mateo Standard Admin Time Schedule). Prior to this project, medication administration times were individualized based on pharmacy dispensing of orders and individual needs of patients. Interruptions/distractions by nurses, MDs, healthcare team members, patients and family members were discouraged during the medication administration hour.
Identify key stakeholders and the barriers that were overcome.
What were the biggest risks related to the project?
Describe the outcomes and conclusions extrapolated from the findings.
How was it determined that the project was successful?
For example, describe the metrics and measures used to identify before and after changes.
The project utilized CalNOC indicators to observe and identify baseline and improved measures.
The implementation of project measures decreased interruptions and increased medication administration accuracy on both units.
Interruption Reduction
In the year prior to implementing the project (2008-2009), participating Medical Surgical unit nurses experienced interruptions during medication administration 24% of the time, while the participating ICU experienced interruptions 31% of the time. After project implementation
(2009) the Medical-Surgical unit realized a 13% reduction in interruptions. The ICU realized a
23% reduction.
Error reduction
The Med-Surg unit began with a 97% administration accuracy rate in 2008-2009, increasing to
99% accuracy in 2009 after project implementation. The ICU increased medication administration accuracy from 88% to 95%.
Describe the most important tips and strategies needed to implement these findings in daily

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practice. What settings can these findings be implemented in successfully?
1.) Designated a medication pass time-out from 8-9 am with algorithm based on med times *
2.) Post flyers/posters in Pyxis, patient rooms, nursing stations and hallways notifying individuals of the med admin hour and no interruption protocol *
3.) Gave letters to patient upon admission to the unit regarding medication safety/no interruptions *
4.) Unit secretary announcement in English and Spanish during medication pass time-out
5.) Letters to MDs and other healthcare members on new protocols *
6.) Visitor brochures asking for no interruptions during medication administration
7.) Asked unit secretary to take messages for phone calls during medication pass time-out *
* See attached documents for samples
Describe the financial and resource needs, as well as the cost savings, associated with the project.
There are five main core leadership competencies identified by ICLN. These are as follows:
Emotional intelligence, professional communication, interprofessional collaboration,
organizational savvy, patient care excellence.
Describe the strategies used to enhance these values during project implementation.
Please share your efforts to sustain the improvements to your unit/facility.
1.) Continue with monthly unit meetings
2.) Unit team leaders will continue to be unit champions
3.) Involve other staff in data monitoring
4.) Quality Management will continue to support the unit in analyzing the data
5.) Addition to the New Nurses Orientation agenda
6.) Monthly reporting of data to management and staff during monthly staff meetings

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