Quantifying nursing workflow in medication administration

New medication administration systems are showing promise in improving patient safety at the point of care, but adoption of these systems requires significant changes in nursing workflow. To prepare for these changes, the authors report on a time-motion study that measured the proportion of time that nurses spend on various patient care activities, focusing on medication administration-related activities. Implications of their findings are discussed.     

Nursing medication administration and workflow using computerized physician order entry

The benefits of computerized physician order entry systems have been described widely; however, the impact of computerized physician order entry on nursing workflow and its potential for error are unclear. The purpose of this study was to determine the impact of a computerized physician order entry system on nursing workflow. Using an exploratory design, nurses employed on an adult ICU (n = 36) and a general pediatric unit (n = 50) involved in computerized physician order entry-based medication delivery were observed. Nurses were also asked questions regarding the impact of computerized physician order entry on nursing workflow. Observations revealed total time required for administering medications averaged 8.45 minutes in the ICU and 9.93 minutes in the pediatric unit. Several additional steps were required in the process for pediatric patients, including preparing the medications and communicating with patients and family, which resulted in greater time associated with the delivery of medications. Frequent barriers to workflow were noted by nurses across settings, including system issues (ie, inefficient medication reconciliation processes, long order sets requiring more time to determine medication dosage), less frequent interaction between the healthcare team, and greater use of informal communication modes. Areas for nursing workflow improvement include (1) medication reconciliation/order duplication, (2) strategies to improve communication, and (3) evaluation of the impact of computerized physician order entry on practice standards.     

Scanning for safety: an integrated approach to improved bar-code medication administration

This is a review of lessons learned in the postimplementation evaluation of a bar-code medication administration technology implemented at a major tertiary-care hospital in 2001. In 2006, with a bar-code medication administration scan compliance rate of 82%, a near-miss sentinel event prompted review of this technology as part of an institutional recommitment to a "culture of safety." Multifaceted problems with bar-code medication administration created an environment of circumventing safeguards as demonstrated by an increase in manual overrides to ensure timely medication administration. A multiprofessional team composed of nursing, pharmacy, human resources, quality, and technical services formalized. Each step in the bar-code medication administration process was reviewed. Technology, process, and educational solutions were identified and implemented systematically. Overall compliance with bar-code medication administration rose from 82% to 97%, which resulted in a calculated cost avoidance of more than $2.8 million during this time frame of the project.     

Concept analysis: an approach to teaching physiologic variables

Establishment of a knowledge base for nursing practice has been an ongoing goal of nurse professionals for the past decade. Because nurses are especially concerned with management of the body's potential or actual response to illness, the development and use of materials that reflect these body responses seems appropriate. This article is an effort to promote the use of concepts as a basis for nursing practice. A concept analysis approach for didactic instruction, currently being used for organizing and synthesizing pathophysiologic data present in literature, is presented. The process is exemplified by excerpts from the concept "inflammation." Advantages and disadvantages identified by graduate students for the use of concepts and the analysis process as a teaching/learning strategy are included.     

Descriptive analysis of pro re nata medication use at a Canadian psychiatric hospital

Pro re nata (PRN), a Latin phrase meaning ‘as needed’, is used to describe medications that might be used in specific situations, in addition to regularly‐scheduled medications, such as when a patient is particularly anxious, experiencing insomnia, or suffering pain. While helpful in some circumstances, PRN are associated with an increased risk of morbidity, overuse, dependence, and polypharmacy. There is also a dearth of medical literature describing current practices and trends of PRN administration in mental health facilities, especially in Canada, and the literature that does exist is limited by poor documentation practices. Therefore, the primary objective of the current study was to understand the reason (purpose), frequency, use, documentation practices, and outcome (i.e. effectiveness, side‐effects) of PRN medication use on inpatient units. Data were pulled to capture a snapshot of PRN administrations over a 3‐month period, and included information related to the administration of the PRN medication, such as time of administration, type and dose of PRN medication, and prescribed indication, as well as patient‐specific information. Results indicated that approximately 8200 psychotropic PRN medications were administered during the designated 3‐month time period, and over 90% of patients received at least one PRN. Most of these were benzodiazepines, followed by antipsychotics. Further analyses were conducted to determine other characteristics of PRN use patterns and to provide a baseline of understanding that will inform future research to investigate the practice of PRN administration to psychiatric inpatients.     

Nurses' satisfaction with medication administration point-of-care technology

Efforts to promote safe care prompted the development point-of-care technology, but successful adoption requires acceptance by nursing staff. To assess the satisfaction of nurses who use point-of-care technology that integrates nurse scanning of bar-coded medications with the patient's electronic medication administration record, the authors examined nurses' satisfaction with barcode/electronic medication administration record before and after introduction in an academic medical center.     

护士发生给药错误的特点及原因分析

目的分析护士给药错误发生的特点和原因,探讨如何预防给药错误的发生。方法回顾性分析某三级甲等医院2010年至2012年自愿非惩罚报告系统中上报的给药错误137例,分析护士给药错误的类别、特点及原因。结果给药错误主要发生在综合科室占31.39%,外科占24.82%;患者身份识别错误、药物遗漏、给药技术性错误是给药错误的主要类别;发生给药错误的药物种类,占前2位的分别是抗生素和心血管系统用药;在发生给药错误的原因中,操作过程中没有认真执行查对制度占48.91%。结论护理管理者应根据给药错误的特点制订相应的管理措施,加强护士药物知识的培训,严格执行查对制度,降低给药错误的发生。     

School nurses' experiences with medication administration.

This article reports school nurses' experiences with medication administration through qualitative analyses of a written survey and focus groups. From a random sample of 1000 members of the National Association of School Nurses, 649 (64.9%) school nurses completed the survey. The quantitative data from the survey were presented previously. However, 470 respondents provided written comments on the survey. Comments on the eight items that had the most written comments were qualitatively analyzed. In addition, to clarify information obtained from the surveys, two focus groups with local school nurses were conducted. A constant comparative method of analysis was used, and results were combined from the two data sources. The combined analyses resulted in six final categories of concern: (a). delegation of medication administration, (b). comfort with delegation, (c). self-administration of medication, (d). medication administration errors, (e). storage of medication, and (f). administration policies. The findings suggest that school nurses across the country have similar concerns regarding the administration of medications in the school setting.     

Using snowball sampling method with nurses to understand medication administration errors

Aims and objectives. We aimed to encourage nurses to release information about drug administration errors to increase understanding of error‐related circumstances and to identify high‐alert situations. Background. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Methods. Snowball sampling was conducted to recruit participants. A semi‐structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Results. Eighty‐five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one‐third of total errors. Among 259 actual errors, 83·8% resulted in no adverse effects; among remaining 16·2%, 6·6% had mild consequences and 9·6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double‐check procedures by colleagues and nurses responsible for errors; reporting rates were 62·5% (162/259) vs. 50·7% (35/69) and only 3·5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High‐alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Conclusions. Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high‐alert situations. Strategies for reducing drug administration errors by nurses are suggested. Relevance to clinical practice. Survey results suggest that nurses should double check medication administration in known high‐alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non‐reprimanding atmosphere, helping to establish standard operational procedures for known high‐alert situations.     

Applying airline safety practices to medication administration.

Medication administration errors (MAE) continue as major problems for health care institutions, nurses, and patients. However, MAEs are often the result of system failures leading to patient injury, increased hospital costs, and blaming. Costs include those related to increased hospital length of stay and legal expenses. Contributing factors include distractions, lack of focus, poor communication, and failure to follow standard protocols during medication administration.     

Nursing satisfaction with implementation of electronic medication administration record

Nurses' perceptions of electronic medication administration record documentation versus medication administration record documentation over time in workload, teamwork, ease of documentation, drug information accuracy, patient safety, and overall satisfaction are not well understood. Using survey methods and a longitudinal design, nurses administering medications completed the Nursing Satisfaction with eMAR instrument anonymously after electronic medication administration record implementation and at 3 and 6 months. Data were analyzed using comparative and correlational statistics, and analysis-of-variance models used to complete multivariable regression. Participants were 719 nurses: baseline, n = 389; 3 months, n = 213; and 6 months, n = 117. Electronic medication administration record documentation was associated with perceived improvement in overall nurse satisfaction, workload, teamwork, ease of documentation, drug information accuracy, and patient safety across time periods (all P < .001) and in trends across time, (all P < .001). After regression, electronic medication administration record satisfaction improved across time periods (all P < .02), with the greatest improvement between baseline and 6-month follow-up (P < .001). An electronic medication administration record documentation system is associated with overall nurse satisfaction and perceptions of improvement in workload, teamwork, ease of documentation, drug information accuracy, and patient safety but not nurse/pharmacy communication. Since timeliness and accuracy of nurse/pharmacy communication remain key components to safe and timely medication administration and documentation, nurse and pharmacy personnel should develop alternate systems of communication.