Medical article: improving medication administration safety in a

November-December 2017 • Vol. 26/No. 6374

Janet Tompkins McMahon, DNP, RN, ANEF, is Clinical Associate Professor of Nursing,
Towson University, Towson, MD; and Nurse Educator-Integration Specialist, ATI Nursing
Education.

Improving Medication
Administration Safety in the

Clinical Environment

W
ork interruptions create
danger at the bedside,
particularly during med-

ication administration. A work
interruption can be as simple as a
telephone call, noise, or an invita-
tion to conversation by a member
of the healthcare team, patient, or
family member while the nurse is
preparing medications. Medication
errors are a major concern for
patients and can lead to unneces-
sary safety risks (Karavasiliadou &
Athanasakis, 2014). Reduction of
interruptions and associated errors
with medication administration is
essential.

Project Site and Reasons
for Change

The identified need for change
was reduction of errors and distrac-
tions during medication administra-
tion. The current use of a no-inter-
ruption zone on a medical-surgical
unit was identified by the project
leader as an area for improvement
based on repeated observations of
nurses’ nonadherence to the zone
during eight random visits. Nurses,
other unit staff, and interprofession-
al team members appeared unaware
of or ignored the purpose of the no-
interruption zone.

Some institutions have adopted
use of medication safety vests for
nurses to wear to alert colleagues
and patients of their involvement in
medication administration. Accord –
ing to Williams, King, Thompson,
and Champagne (2014), safety vests,
posted signs, highlighted decorative
aprons, and sashes have been used
to reduce work interruptions. The
project leader decided to incorpo-
rate situation awareness (SA) with the
use of a medication safety vest and

signage on the nursing unit and
within patient rooms (“Do Not
Disturb the Nurse during Medicat –
ion Admini stration”). SA refers to a
practitioner’s conscious awareness
of a circumstance or situation (Stub –
bings, Cha boyer, & McMurray,
2012). An educational in-service
reinforced the purpose and rationale
for the project.

Program
The project leader, a student in a

Doctor of Nursing Practice (DNP)
program, was interested in develop-
ing a capstone project for continu-
ous quality improvement (CQI).
She requested a meeting with the
chief nursing officer (CNO) and
unit nurse manager to address the
observed clinical problem. The
CNO encouraged pursuit of this
CQI opportunity. Project planning
began after the project leader
received approval from the facility
administrator.

Clinical nurses on the unit were
advised of the project 3 months
before its initiation through com-
munication during staff meetings.
The project leader attended meet-
ings the day before the launch to
provide education regarding project
implementation, including creation
of SA, use of the medication safety

vest and signage, and completion of
surveys about adherence to the no-
interruption zone. According to
Sitterding, Ebright, Broome, Patter –
son, and Wuchner (2014), the need
to understand interruptions with
medication administration is neces-
sary.

Disposable medication safety
vests (Riskologic, LLC) were donat-
ed to the project leader for use by
the registered nurses (RNs) identi-
fied as responsible for medication
administration after the education-
al session was completed. A vest
labeled Do Not Disturb was used as a
visual prompt to people who might
approach nurses during medication
administration. “Do Not Disturb
the Nurse During Medication
Administration” signage also was
placed in medication preparation
areas and all 28 patient rooms.
Surveys regarding distractions, use
of a medication safety vest and sig-
nage, and evaluation of the project
leader’s educational program were
included.

MADOS Survey
RNs completed a pretest/posttest

survey on types of distractions. The
Medication Administration Dis trac –
tion Observ ation Sheet (MADOS)
identified 10 sources of distractions
and interruptions (Pape, 2003).

Continuous Quality ImprovementContinuous Quality Improvement

Janet Tompkins McMahon

Work interruptions during medication administration are a serious
problem negatively impacting patient safety. Using a medication
safety vest and signage during medication administration improves
situation awareness, reducing the potential for interruptions.

November-December 2017 • Vol. 26/No. 6 375

pleted and placed in a designated
locked box on the nursing unit for
the project leader’s collection. To
ensure communication for the proj-
ect, the anticipated time frame and
overall project information were
documented in minutes from the
nursing unit meetings each time
the project leader shared additional
information. After completion of
the 4-week project, the MADOS sur-
vey was administered by the project
leader to RNs on both 12-hour
shifts. Those not present for the
final meeting again were given the
survey in their mailboxes with
instructions to place completed sur-
veys in the designated locked box
located on the nursing unit.

Adherence Survey
During the initial meeting about

the project, an adherence survey tool
was introduced to RNs. The survey
was a new tool developed by the
project leader to evaluate previous
adherence to use of the medication
safety vest. The project leader’s DNP
committee provided feedback re –
garding content of the new tool
before its initial use. The nurse unit
had designated nursing leaders in
place with resource nurses staffed on
every 12-hour shift. Resource nurses
(baccalaureate-prepared nurs es) were
invited and encouraged to be cham-
pions for the project. Champions
evaluated medication safety vest
use on 12-hour shifts daily by
completing The Medication Safety
Vest Compliance Report. Designated
cham pions collected data every 12-
hour shift each day for the project
as requested by the project leader
during orientation to the pilot
study. The report listed percentage
ratings (100%-90%, 89%-80%, 79%-
70%, 69%-60%, 59% and below) cor-
responding to a grade of A, B, C, D,
or E, respectively. Champions
assigned a letter grade to RNs admin-
istering medications to patients
every 12 hours for the 4-week period.
Completed daily reports were placed
in designated locked boxes located
in the areas identified on the nursing
unit during the educational in-ser-
vices at the nurses’ station.

Perceptions Survey
A perceptions survey was dis-

cussed and reviewed during staff
meetings, and administered after

Literature Summary
• Cooper, Tupper, and Holm (2016) found 63% of medication passes

(n=30) were caused by interruptions during medication administration at
a 271-bed Magnet® facility, resulting in decreased efficiency.

• Medication errors occur often within nursing practice compared to other
types of errors (Tzeung, Yin, & Schneider, 2013).

• An integrative review by Hopkinson and Jennings (2013) found various
interventions can be implemented to reduce work interruptions during
medication administration, noting future research would be beneficial.

• Keers, Williams, Cooke, and Ashcroft (2013) found slips and lapses were
common during medication administration. Other influences included
written communication errors, perceived workload, and distractions and
interruptions.

• Williams, King, Thompson, and Champagne (2014) found safety vests,
posted signs, and use of highlighted decorative aprons and sashes
reduced work interruptions during medication administration.

• According to Sitterding, Ebright, Broome, Patterson, and Wuchner
(2014), a gap in knowledge and understanding of situation awareness
exists during medication administration.

CQI Model
Plan, Do, Check, and Act (PDCA) model (Russell, 2010)

Quality Indicator with Operational Definitions & Data Collection Methods
• The number of medication errors on the unit was examined with data

extrapolated from the hospital medication variance reporting system.
• The number of distractions was evaluated by the Medication

Administration Distraction Observation Sheet (MADOS). The MADOS
identified 10 sources of distractions and interruptions (Pape, 2003). The
MADOS was used pre- and post-project.

• Adherence to use of the medication safety vest was documented on the
Medication Safety Vest Report each day during the 4-week project period.

• Effectiveness of the medication safety vest use, signage, educational ses-
sions, and reference binder was evaluated after the project. A survey tool
(Nurses Perceptions of the Medication Safety Vest, Signage, and
Education Survey) also was used.

Clinical Setting
28-bed medical-surgical unit (average daily census 25-28 patients) in a 251-
bed regional medical center

Program Objectives
• Decrease number of medication errors on the designated nursing unit.
• Create situation awareness to reduce distractions and medication errors

during medication administration with use of the medication safety vest
and unit signage.

Examples in cluded telephone calls,
interactions with patients and visi-
tors, wrong dose, missing medica-
tions, physicians, and external nois-
es. The modified survey tool (used
with permission from the publisher)
identified nurses’ perceptions of the
reasons and frequency of distrac-
tions during the medication admin-
istration. Nurses also were asked to
identify the 10 most frequent dis-
tractions (1=most frequent, 10=least
frequent). This was ex plained to RNs

during the in-service by the project
leader, and was reinforced on the
MADOS form for RNs to see when
following the directions. Descriptive
statistics were used to examine these
categorical data.

The MADOS survey (Pape, 2003)
was provided to all RNs attending
the educational meeting the day
before the project began, and dis-
tributed in RNs’ mailboxes for those
not present at the meeting. These
additional surveys were to be com-

Improving Medication Administration Safety in the Clinical Environment

November-December 2017 • Vol. 26/No. 6376

Continuous Quality Improvement

the 4-week project. The tool cap-
tured RN perceptions of the medica-
tion safety vest, signage, and educa-
tional sessions. The survey was
developed by the project leader
with the assistance and feedback of
content experts on the DNP com-
mittee.

Evaluation and Action Plan
Data from the Medication Var –

iance Reporting System (MVRS),
which tracks medication errors in
the hospital, were evaluated for 3
months before and 4 weeks after
the project. Results of the MADOS
surveys also were reviewed and ana-
lyzed. Perceptions of medication
safety vest and signage use, educa-
tional session, and reference binder
effectiveness were analyzed. Ad –
herence to safety vest use was eval-
uated as well. Project results were
shared with the unit nurse manager
and RNs as well as the CNO to
begin discussions about potential
change based on results.

Results and Limitations

Results
MVRS results identified an 88%

decrease in medication error rates
after implementation of the med-
ication safety vest. Nine medication
errors were reported by unit nurses
3 months before the project. Use of

the medication safety vest and sig-
nage contributed to a clinically sig-
nificant reduction to one medica-
tion error during the 4-week project
period. Importantly, the single error
was related to a patient’s cardiac
arrest when the safety vest was not
in use.

Per MADOS survey results, exter-
nal noises demonstrated a signifi-
cant change (p=0.03). A two t-test
was performed on the MADOS
results because of the small sample
size (see Figure 1).

Perceptions of the project were
favorable (n=17). For 82% of RNs,
signage in the patient rooms was
always or often effective. Signage in
the medication areas was always or
often effective in 89% of cases. The
medication safety vest was reviewed
favorably 4% of the time. No nega-
tive responses were recorded by RNs.

Adherence results for use of med-
ication safety vests were above aver-
age on both shifts (n=42). RNs used
the medication safety vest 86% of
the time over the 4-week period as
evaluated by champions and the
project leader. This result demon-
strated above-average use of the
medication safety vest during med-
ication administration (see Figure 2).

Field Log Visits
The random eight field log visits

by the project leader identified sub-
jective feedback from nurses during
the 4-week medication safety vest

use. Visits occurred on all shifts and
on weekends. RNs stated they liked
wearing the vest, and noted it
worked. Some RNs admitted they
would forget to use the vest during
medication administration. Two RNs
noted staff from other departments
did not like the vest. They stated
interprofessional team members
expressed frustration when they
could not interrupt the nurse during
medication administration to re –
trieve patient information. One RN
indicated a patient’s family member
asked for a safety vest for the use of
her daughter (an RN at another hos-
pital) because she thought it was a
wonderful idea for patient safety.
Two RNs did not want to stop wear-
ing the vest after the project ended;
they noted it worked in decreasing
interruptions and helped them
become more efficient.

Limitations
Limitations included the sample

size (n=28), response time, and
incomplete sets of MADOS surveys.
A sample size should be greater
than 30 when using central limit
theorem to allow increased variabil-
ity and distribution of results
(Cooper & Schindler, 2003). In
addition, results could have been
affected if nurses changed behavior
and wore the vest when the project
leader made rounds for the observa-
tion and field log. Finally, the tele-
phone was a potential distraction

FIGURE 1.
The Frequency of Distractions Ranked on 1-10 Scale Pre/Post Pilot Survey

Ra
nk
in
g

10
8
6
4
2
0

Ph
ys

icia
n

Ot
he

r P
ers

on
ne

l

Ph
on

e
Ot

he
r P

ati
en

t

Vis
ito

r
Mi

ss
ing

M
ed

ica
tio

n
Wr

on
g D

os
e

Em
erg

en
cy

Co
nv

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ati

on
Ex

ter
na

l N
ois

es

MADOS Survey
Before Vest After Vest

November-December 2017 • Vol. 26/No. 6 377

Improving Medication Administration Safety in the Clinical Environment

during the 4-week project time.
Because nurses were required to
carry a phone at all times, this dis-
traction could not be eliminated;
MADOS results identified it as the
primary distraction.

Lessons Learned/
Nursing Implications

The timeline to begin and fore-
cast a project may not be as easy as
it appears initially. The project
required a forecasted timeline
months in advance to plan the proj-
ect adequately and communicate
needs with staff at the acute care
facility. Any project or quality
improvement study requires critical
thinking and careful judgment by
the project leader. Institutions have
their own schedules and needs
which come first, sometimes requir-
ing reorganization of anticipated
needs to another time or day.
Meetings can be cancelled and may
not be the priority for facility staff.
Schedules may not match, creating
a longer window of anticipation for
implementation. The experience
can be improved with enhanced
knowledge and communication of
medication error, rationale, types of
distractions, and need for practice
changes to improve outcomes with
interprofessional efforts.

The biggest lesson from the proj-
ect involved the need for communi-
cation with all stakeholders to

ensure success. The project leader
must be a strong communicator
and organizer. The project required
continuous monitoring as well as
written and in-person communica-
tion. Accountability with project
expectations also is paramount for
success. Use of effective communi-
cation methods for participants
reduces knowledge gaps to allow
the project to proceed as planned.

In addition, the project leader
must be flexible and willing to
make changes with timelines. Not
everyone shares the same passion
for meeting project goals. Institut –
ional priorities may not be the proj-
ect leader’s priorities, so flexibility
with planning and organizational
forecasting is critical.

Such a project can guide nurse
practice changes to im prove patient
safety outcomes and reduce medica-
tion errors. The SA created through
use of the safety vest contributed to
reduced distractions and medication
errors. With reduced distractions
while wearing the medication safety
vest, RNs could focus more closely
on administering medications. In
addition, the interprofessional team
became more independent in ob –
taining information about pa tients
without interrupting medication
administration. Further investiga-
tion or replication of the project
would be beneficial to the nursing
profession and for patient safety
outcomes.

A positive change in RNs’ behav-
ior included their request to contin-
ue to use the medication safety
vests after the project. RNs identi-
fied a desire to address a policy
change for using the vest during
medication administration to con-
tinue the reduction of potential
medication errors from less distrac-
tions on the unit by members of the
healthcare team, patients, and fam-
ilies. Signage used in conjunction
with the medication safety vests
and SA appeared to be effective as
unit staff asked to keep all signage
in patient rooms and medication
administration area. To date, “Do
Not Disturb the Nurse during
Medication Administration” sig-
nage still is used on the unit at the
regional medical center.

Conclusion
The CQI project demonstrated an

evidence-based solution to reduce
errors and improve patient safety
with medication administration.
Medication errors decreased during
the 4 weeks of the project while
nurses wore the safety vest, and with
placement of signage on the nursing
unit in patient care areas during
medication administration. Use of
medication safety vests and signage
is a potential solution for reducing
errors and distractions during med-
ication administration. Creating SA
among nurses, other healthcare pro-
fessionals, patients, and families
using a medication safety vest, sig-
nage, and education is vital for qual-
ity improvement. Reduction of
medication errors and distractions
for nurses during a critical skill inter-
vention with patient care is advan-
tageous.

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Cooper, C.H., Tupper, R., & Holm, K. (2016).
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Hopkinson, S.G., & Jennings, B.M. (2013).
Interruptions during nurses’ work: A
state-of-the-science review. Research in
Nursing and Health, 36(1), 38-53. doi:
10.1002.nur21515

continued on page 409

FIGURE 2.
Adherence

50
45
40
35
30
25
20
15
10
5
0

Pe
rc
en
ta
ge

A
(90-100)

B
(89-80)

C
(79-70)

D
(69-60)

E
(≤59)

Adherence Grades

45%
41%

7%
2%

5%

November-December 2017 • Vol. 26/No. 6 409

Improving Medication
Administration
continued from page 377

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073 43.7f

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