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Individual:Analyzing Published Research Articles (IAPRA) Paper

Purpose

· The purpose of this paper is to interpret the article as most relevant to the group topic.

· Analyze one primary data research article most relevant to your group topic and research question.

Course Outcomes

This assignment enables the student to meet the following course outcomes:

CO 2: Apply research principles to the interpretation of the content of published research studies (PO#4 & 8).

CO 4: Evaluate published nursing research for credibility and clinical significance related to evidence-based

practice (PO#4 & 8).

Due Date (please see course calendar for specific dates/times)

· Week 4, Part I

· Week 4, Part II

· Week 5, Part III

· Week 5, Part IV

· Week 6, Part V

· Week 6, Part VI

· The Late Assignment Policy applies to this assignment.

Points Possible
: 220 Points

Paper Preparation:

· It is NOT acceptable to use bullet-points in the body of text review paper.

· All review contents must be PARAPHRASED with your OWN words with in-text citations.

· It is NOT acceptable to QUOTE article contents
EXCEPT
the
Purpose of Study
as required.

· Paper must include all required APA-Style/Format

· Do
NOT
leave blank for any of these review elements.

· Any review element left blank will get 0 point: If authors did not provide information or it was not applicable for certain elements, make note such as “No information was given” or “Not applicable”

PLAGIARISM: “Turnitin” Percentage

· Less than 25 percentage: Acceptable percentage.

· Turnitin Draft Submission Box

· Submit your draft of paper into Turnitin Draft Submission Box to check your percentage as many times as needed before you submit your final paper to designated Unit.

· If your Final paper has 25% or higher percentage, you must revise/modify your paper contents
BEFORE
you submit your paper due date and time.

· If your Final paper has 25% or higher percentage
AT/AFTER
you submit your final paper due date and time, Academic Integrity Violation Procedures will be initiated

Academic Integrity Violation Procedure

· Academic Integrity Violation letter will be sent to student

· Assignment Grade will be 0 point

· The violation case will be reviewed, and a further sanction will be determined by the Administrators

Individual Analyzing Published Research Article (IAPRA)

Part I: Research Question, Purpose, Variables and Participants

Research Question

· Clearly and concisely states your group research question as formulated in PICO format.

Purpose of the Study

· Describe the purpose/aim of the study as the author stated in the article: may cut & paste

· Do
NOT
change or modify the purpose statement on the article

Variables

· Identify study variables from the above stated Purpose of Study

· Quantitative Study: Dependent & Independent Variables
OR
Descriptive, Qualitative Study: Variables of Interest

Participants

· Enrollment: How did they recruit/enroll eligible participants in the study?

· Inclusion & Exclusion Criteria: Describe Inclusion & Exclusion Criteria

· Total Participant Numbers: Total numbers of participants in the study

Part II: Intervention Procedures/Obtaining Information Procedures

Quantitative Study

Intervention/Treatment Group

· Describe the intervention contents given to Intervention group

· Describe how the contents were given to Intervention group

· Identify the person who provided Intervention contents to Intervention group

Control Group: If the study has Control Group

· Describe the contents given to Control group

· Describe how the contents were given to Control group

· Identify the person who provided contents to Control group

Descriptive/Qualitative Study: Obtaining Information Procedure

· Describe the detailed procedure for obtaining information/data (i.e. made appointment to meet each participant, visited home/met in clinical setting……etc)

Part III: Data Collection Procedures & Measurement Tools/Instruments

· Describe ALL methods to collect data in detail (i.e. interview, survey, observation……etc.)

· Describe
each
measurement tool/instrument used to measure/assess outcomes in the study in detail.

Part IV: Results/Findings

Participant Characteristics/Sociodemographic Findings

· Describe participant characteristics or sociodemographic status

· Must be objective, descriptive, and comprehensive

· Must describe the findings of Tables/Figures to provide comprehensive information about participant characteristics as article provided.

Study Results/Findings

· Describe
ALL

Other Results/Findings besides above participant characteristics in detail.

· Each result item must include Headings/Subheadings as the article provided.

· Do
NOT
simply saying “pain level was decreased,” “adherence was increased”…etc

· Do
NOT
include contents from Discussion and/or Conclusion in the article.

Part V: Synthesis of Findings

Synthesis of Findings

· Describe the
Rationale/Mechanism
for how/why
Finding
of each intervention/factor helps your Research Question (i.e. how/what mechanism does music therapy help pain, how does sucking stimulation increase oral intake for pre-term infants)

· Should
NOT
repeat same contents you had on Findings section and/or article

· May include citations from other sources for above described rationale/mechanism (i.e. textbooks, CDC…etc)

Nursing Implications

· How the nurses can implement the research findings into nursing practice.

Part VI: Group Article Summary Table (All group members)

· Describe each group member’s article on Research Article Summary Table.

· Use bullet points for each review content

Grading Rubric & Description for IAPRA

Part I (40)

Research Question

· Accurately/Clearly states group’s Research Question as your group formulated

Format

Followed APA format for paper, in-text citation, references.

Purpose of Study

· Describe the purpose of the study as the author stated in the article.
· Do
NOT
change or modify the statement on the article

Variables

· Identify study variables from the above stated Purpose of Study
· Quantitative Study: Dependent & Independent variables

· Descriptive, Qualitative Study: Variables of Interest

Participants

5
5
5

· Enrollment: How did they recruit eligible participants in the study?
· Eligibility: Describe Inclusion & Exclusion Criteria
· Numbers: Total numbers of participants in the study

Part II (45)

Intervention Procedures

Obtaining Information Procedures

Quantitative Study:
· Intervention Group: Describe the detailed Intervention contents, procedures, and person who provided Intervention for Intervention group.
· Control Group: Describe the detailed contents, procedures, and person who provided contents for Control group
OR

Descriptive Study:
· Describe the detailed procedure for obtaining information/data (i.e. made appointment to meet each participant, visited home/met clinical……etc)

Format

Followed APA format for paper and in-text citations

Part III (40)

Data Collection

Measurement Tools

5
35

· Describe ALL data collection methods in detail (i.e. survey, interview, observation)
· Describe each measurement tool/instrument used to measure study outcomes in detail.

Format

· Followed APA format for paper and in-text citations

Part IV (50)

Participant Characteristics/Sociodemographic Findings

All other Results/Findings

· Must be descriptive and comprehensive
· Describe participant characteristics or sociodemographic findings
· Describe the findings of Tables/Figures to provide comprehensive information about participant characteristics as article provided

· Describe
ALL
Other Results/Findings besides above participant characteristics in the article in detail for each Result item
· Each Result item must include Headings/Subheadings of Results as the article provided.
· Do
NOT
simply saying “pain level was decreased,” “adherence was increased”
· Do
NOT
include contents from Discussion and/or Conclusion in the article.

Format

· Followed APA format for paper and in-text citations

Part V (20)

Synthesis of Findings

· Describe the
Rationale
for how/why
Finding
of each intervention/factor helps your Research Question (i.e. how/what mechanism does music therapy help pain, how does sucking stimulation increase oral intake for pre-term infants)
· Should
NOT
repeat same contents you had on Findings section and/or article
· Should have citation of analyzed article(s)
· May include citations from other sources for above described rationale and mechanism (i.e. textbooks, CDC…etc)

Nursing Implication

· How the nurses can implement the research findings into nursing practice?

Format

· Followed APA format for paper, in-text citation, references.

Part VI (25)

Article Summary Table (Group)

· Describe article on Research Article Summary Table
· Use
bullet points
for each review content
· Submit Table as separate document

Total Points: 220 Points

Cover

16 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn201649

CE 1.0 hour

Fran Flynn, APRN, MS, BC-CNS
Julie Q. Evanish, RN, BS, PCCN
Josephine M. Fernald, RN, BSN, PCCN
Dawn E. Hutchinson, RN, BSN, PCCN
Cheryl Lefaiver, RN, PhD, CCRP

Progressive Care Nurses
Improving Patient Safety by
Limiting Interruptions During
Medication Administration

BACKGROUND Because of the high frequency of interruptions during medication administration, the
effectiveness of strategies to limit interruptions during medication administration has been evaluated in
numerous quality improvement initiatives in an effort to reduce medication administration errors.
OBJECTIVES To evaluate the effectiveness of

evidence-based strategies to limit interruptions during

scheduled, peak medication administration times in 3 progressive cardiac care units (PCCUs). A sec-
ondary aim of the project was to evaluate the impact of limiting interruptions on medication errors.
METHODS The percentages of interruptions and medication errors before and after implementation of
evidence-based strategies to limit interruptions were measured by using direct observations of nurses
on 2 PCCUs. Nurses in a third PCCU served as a comparison group.
RESULTS Interruptions (P < .001) and medication errors (P = .02) decreased significantly in 1 PCCU after implementation of evidence-based strategies to limit interruptions. Avoidable interruptions decreased 83% in PCCU1 and 53% in PCCU2 after implementation of the evidence-based strategies. CONCLUSIONS Implementation of evidence-based strategies to limit interruptions in PCCUs decreases avoidable interruptions and promotes patient safety. (Critical Care Nurse. 2016;36[4]:19-35)

This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:

1. Describe similarities between the principles of the sterile cockpit concept used in the aviation industry and the Nurses Uninterrupted Passing Medications Safely
(NUPASS) guidelines to promote safety

2. Discuss the current evidence supporting use of interruption limiting strategies to reduce medication administration errors in the acute care setting
3. Implement evidence-based strategies to limit interruptions during medication administration

To complete evaluation for CE contact hour(s) for test #C1642, visit www.ccnonline.org and click the “CE Articles” button. No CE test fee for AACN members.
This test expires on August 1, 2019.

The American Association of Critical-Care Nurses is an accredited provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on
Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Registered Nursing of California (#01036) and Louisiana (#LSBN12).

N
urses play a critical role in promoting patient safety through surveillance and inter-

ception of errors that cause patient harm as hospitals and health care systems strive

to become high-reliability organizations.1 The Institute of Medicine estimates that

medication errors result in several thousand deaths annually.2 Interruptions during

complex or high-risk activities such as medication administration increase risk of

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 19

20 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org

Authors
Fran Flynn was the advanced practice nurse on one of the progressive cardiac units at the time of the project and is now the advanced practice
nurse for the inpatient palliative care service, Advocate Christ Medical Center, Oak Lawn, Illinois.

Julie Q. Evanish was a bedside nurse in one of the progressive cardiac units at the time of the project and is now working in the outpatient
pain clinic, Advocate Christ Medical Center.

Josephine M. Fernald was a bedside nurse in one of the progressive cardiac care units at the time of the project and is now working in the
outpatient heart failure clinic, Advocate Christ Medical Center.

Dawn E. Hutchinson was a bedside nurse in a progressive cardiac care unit when the study was done and is now a clinical informatics
specialist, Advocate Christ Medical Center.

Cheryl Lefaiver was the professional nurse researcher for the medical center when the study was done and is now manager of patient-centered
outcomes research for Advocate Center for Pediatric Research, Advocate Christ Medical Center.

Corresponding author: Fran Flynn, APRN, MS, BC-CNS, Advocate Christ Medical Center, 4400 W 95th St, Oak Lawn, IL 60453 (e-mail: fran.flynn@advocatehealth.com).

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

patient harm, and strategies to reduce interruptions

and manage them appropriately are needed.3 On the

basis of the current evidence, the Institute of Medicine

recommends that organizations adopt strategies to

reduce interruptions during medication administration

as part of a comprehensive medication safety program.

The quality improvement project described here

evaluates the impact of adopting evidence-based strate-

gies to limit interruptions during medication adminis-

tration in 2 progressive cardiac care units (PCCUs) at

Advocate Christ Medical Center, a Magnet-designated

tertiary care center in the Midwest. A third PCCU served

as a comparison unit and, therefore, did not adopt the

interruption-limiting strategies. A secondary aim of the

project was to evaluate how limiting interruptions

affected medication errors in this setting.

Background
In a plenary speech at the 2008 National Teaching

Institute, the former president of the American Associa-

tion of Critical-Care Nurses challenged more than 9000

nurses in attendance to avoid multitasking and interrup-

tions when

administering

medications

in order to

prevent medi-

cation errors.

Attendance at this speech was the inspiration for this

project and became the springboard for addressing

existing nursing concerns about interruptions.

Review of the Literature
Observational studies describe the high cognitive

work of nurses coupled with frequent interruptions and

multitasking behaviors during direct patient care activ-

ities in acute care settings.4-8 The work environment is

error-prone, especially during complex or high-risk

activities, because interruptions and multitasking

behaviors create conditions affecting working memory

and attention resources.9,10 Nurses’ cognitive processes

during medication administration are complex and

require a high degree of critical thinking and vigilance

to prevent patient harm.11 Medication administration

is one of the most frequently interrupted nursing

activities,4,6,12 and strategies to limit interruptions are

recommended to improve patient safety.

Studies describing the frequency and characteristics

of interruptions during medication administration show

that nurses have little protected time to focus on medica-

tion administration because of short, frequent interrup-

tions.6-9,12,13 The most common source of interruptions is

interactions with other nursing staff seeking information

or assistance with patient care.13 The frequency of inter-

ruptions by other care providers varied significantly

across studies.13,14 Although they were not the most fre-

quent source of interruptions, phone calls were identi-

fied by nurses as one of the most disruptive sources of

interruptions and one of the most likely sources of inter-

ruptions to be associated with medication errors.8,12

System failures such as missing medications and access

to equipment and supplies were also identified as sources

of interruptions that are potentially avoidable.7,8,12-16

Other avoidable interruptions cited in the literature are

the tendency of nurses to interrupt each other with

conversations unrelated to medication administration7,17-19

while preparing medications and to respond immedi-

ately to requests from others when interrupted.7,15,20

These findings support the idea that interruptions are

an accepted part of nursing practice and suggest the

Attendance at the National Teaching
Institute was the inspiration for this
project and the springboard for
addressing existing nursing concerns
about interruptions.

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 21

need for culture change to limit avoidable interruptions,

especially during complex or high-risk activities such as

medica

tion administration.

Development and testing of strategies to limit inter-

ruptions during the medication administration process

are primarily based on research from the aviation indus-

try. In 1981, the Federal Aviation Authority mandated

use of standard operating procedures to create a sterile

cockpit situation aimed at reducing unsafe working con-

ditions and preventing errors during high-risk activities

such as aircraft takeoff and landing. Essential aspects of

the sterile cockpit concept include eliminating interrup-

tions, prohibiting communication unrelated to critical

tasks, and maximizing teamwork and coordination

during high-risk activities.21,22 The majority of published

clinical initiatives to limit interruptions during medica-

tion administration are nurse-led quality improvement

projects involving implementation of a set of strategies

to limit interruptions (Table 1). The goal of these initia-

tives is to provide nurses with time to remain focused

and undisturbed while preparing and administering

medications. Direct observations of nurses preparing

and administering medications during peak, scheduled

administration times were used to study interruptions

in these quality improvement projects. Results of these

projects demonstrate that implementation of a set of

strategies is effective in limiting interruptions and may

improve patient safety by decreasing medication errors.

To date, 1 study3 examining the direct relationship

between work interruptions and hospital medication

administration errors has been published. Results of this

landmark study demonstrated that the frequency of

interruptions during medication administration increased

the risk of both the number and severity of medication

errors. Table 2 provides a detailed analysis of the litera-

ture regarding cognitive work of nurses and the com-

plexity of the work environment, interruptions during

medication administration, strategies used to limit inter-

ruptions during medication administration, and the

contribution of interruptions to medication errors.

Introduction to the Progressive Cardiac
Care Quality Improvement Project

The PCCU quality improvement project was developed

and implemented on the basis of the work of Nguyen

and colleagues.25 In the quality improvement project

presented here, the project team implemented a set of

evidence-based strategies to limit interruptions during

scheduled, peak medication administration times in

the progressive cardiac care setting. The project team

embedded the interruption strategies into practice guide-

lines to promote communication, coordination of care,

and teamwork during medication administration. The

guidelines are referred to as the “NUPASS guidelines,” on

the basis of the project’s name: Nurses Uninterrupted

Passing Medications Safely (Table 3).

The project’s conceptual framework is

based on the

medical center’s Evidence-Based Practice (EBP) Model

(Figure 1). The EBP model was adopted and modified

on the basis of the Iowa model.30 Using the EBP model

as a guide, the project team initiated a pilot practice

change based on the current evidence supporting use

of strategies to limit interruptions during medication

administration. The pilot practice change was designed

to answer 2 questions: (1) Does implementation of the

NUPASS guidelines decrease interruptions during medi-

cation administration? and (2) Do medication errors

decrease following implementation of NUPASS guide-

lines? The pilot practice change was conducted on 2 of

the 3 PCCUs; PCCU1 and PCCU2 were the intervention

units that implemented the NUPASS guidelines, and

PCCU3 served as

a comparison unit.

Patients cared for in the high-acuity PCCUs typically

included patients who required invasive diagnostic and

interventional cardiovascular procedures, cardiovascular

surgery, and arrhythmia management. Common medi-

cal diagnoses included acute coronary syndrome, heart

Table 1 Evidence-based strategies to limit
interruptions during medication administration

1. Hourly patient rounds23

2. Scripts for triage of phone calls17,22,24-26

3. Protected time for passing medications without
interruptions17,22,

4. Signage to remind staff to limit interruptions12,17,22,24-26

5. “No interruption zone”/“quiet zone” established in
medication rooms17,24-27

6. Phone calls to nurses limited during medication
administration17,25

7. Nurses don visible wear as a nonverbal cue that they
are administering medications and are not to be
disturbed12,17,22,26

8. Distribution of patient/family education materials about
limiting interruptions during medication administration12,17

22 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org22 C i i lC N

Table 2 Detailed review of the literature

Reference

Potter et al,4 2005

Eisenhower et al,11 2007

Kalisch and Aebersold,5
20

Cornell and Riordan,9
2011

Kreckler et al,6 2008

Biron et al,7 2009

Palese et al,8 2009

Biron et al,13 2009

Sample/setting

Convenience sample of 7 nurses with
acute care experience and clinical
background

Large, tertiary medical center in the
Midwest

Convenience sample of 40 nurses
working in intermediate medical-
surgical intensive care unit
(M/S ICU) and ante/postpartum unit

Large, tertiary teaching hospital in
the Northeast

Convenience sample of 36 nurses
from 5 M/S units, 1 ICU, and 1
progressive care unit

Seven patient care units in 2
Midwestern hospitals including
an academic medical center and a
community-based teaching hospital

Convenience sample of 19 nurses
from 2 hospitals including 8 nurses
on an M/S unit at a suburban,
acute care hospital and 11 nurses
on a pediatric oncology unit at a
pediatric research hospital in the
United States

Convenience sample of nurses
working on a 37-bed surgical unit
at a teaching hospital in the United
Kingdom

Convenience sample of 18 nurses
working on a medical unit at a
tertiary care teaching hospital in
Quebec

A convenience sample of nurses
working on 7 surgical units across
multiple, similar type hospitals in
Northern Italy

Articles from 1980 to 2008 were
analyzed

Design/procedures

Mixed method ethnographic observa-
tional study combining quantitative
human factor engineering techniques
with summative nurse interviews

Nurses were observed for a total of 48 h

Descriptive study with semistructured
interviews

Observational study
A previously validated instrument

referred to as the “Communication
Observation Tool” was used by 4
trained staff nurses to collect data

For the purpose of this study, both
procedural failures and medication
administration errors were counted
as errors

Observational study limited to nurs-
ing activities outside of the patient’s
room during 85.2 h of observation

Observational study
Thirty-eight medication passes were

observed in 5 weeks

Observational study
Descriptive data included source and

duration of interruptions, nursing
tasks and location during interrup-
tions and strategies used by nurses
to manage interruptions

Mixed-method study combining
observation of nurses during medica-
tion administration followed by nurse
interviews during a 3-month period

Systematic review
Fourteen of 23 studies selected for

analysis reported observation times
and interruption frequencies and
therefore, underwent further analysis

Purpose

Analyze nurses’ cognitive work
and how environmental fac-
tors create disruptions that
pose risk for medical errors

Describe nurses’ thinking
during medication admin-
istration before and after
implementation of bar-code
medication scanning (point-
of-care technology)

Evaluate the type and extent
of work interruptions, multi-
tasking, and errors

Assess the complexity of
nurse workflow and review
its cognitive implications

Determine the time required
by nurses to deal with inter-
ruptions and the nature of
nurses’ work interruptions
(WIs) during medication
administration

Document characteristics of
nurses’ WIs during medi-
cation administration

Examine the frequency and
perceived risk of WIs during
medication administration

Review the evidence on
nurses’ interruption rates,
characteristics of WIs, and
contribution of WIs to medi-
cation administration errors

A. Cognitive work of nurses and complex work environment

B. Interruptions during medication administration

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 23C i i lC N 23

Findings/conclusions

Nurses averaged 9 cognitive shifts per hour or a shift in attention focus once every 6-7 min
The human factor engineer found 5.9 interruptions per hour and the nurse researcher found an average of 3.4 interruptions per hour
Twenty-two percent of interruptions occurred in the medication room during medication preparation, and no attempt was made by

nurses to control sources of the interruptions

Nurses’ constant vigilance to provide the appropriate medication was a common theme found in the content analysis
Nurses’ thinking was categorized into 10 descriptive categories; the only change in thinking after implementing bar-code scanning was

the descriptive category related to checking medications
Key aspects of critical thinking identified included assessment of the patient before and after administration of medications, interpretation

and verification of relevant laboratory data, application of knowledge to specific patient situations, anticipatory problem solving related
to the patient’s expected clinical trajectory and consultation with health care team members to prevent medication errors and adverse
drug events

The mean interruption rate observed at the 2 hospitals was 10 interruptions per hour resulting in a break in task more than 1/3 of the time
Interruptions occurred every 6 minutes for hospital 1 and every 4.5 min for hospital 2; nurses were interrupted during medication

administration 57% and 36% of the time in hospital 1 and hospital 2, respectively
Nurses engaged in multitasking an average of 30% and 40% of the time in hospital 1 and hospital 2, respectively
Significantly more interruptions (P < .001), multitasking (P < .001), and breaks in task (P < .001) occurred in ICUs than in the M/S units No more errors were found when nurses were interrupted or multitasking vs when nurses were not interrupted or multitasking

More than 2000 tasks were recorded on each unit during 35.7 h of observation on the M/S unit and 49.5 h of observation on the pediatric
oncology unit

The duration of tasks was short with a mean of 62.4 (SD, 127.7) s and 49.5 (SD, 81.6) s on the M/S unit and pediatric oncology unit,
respectively

The reason for switching tasks (self-directed or external) was not discernible
Nurses frequently changed locations when switching tasks

Medication passes were interrupted a mean of 11% of the time
Two-thirds of the medication passes were interrupted with a mean of 2.61 interruptions per medication pass
The 3 most frequent sources of interruptions in descending order were (1) interruptions by the nurse administering medication (self-initiated),

(2) interruptions by physicians, and (3) interruptions by other staff and patients
Phone calls were not the most frequent source of interruption; however, they were found to be significant because of their longer duration

WIs averaged 6.3 per hour (5.2 per hour during medication preparation and 6.8 per hour during medication administration)
WIs were of short duration with a mean of 1 min 32 sec (SD, 2 min)
The most frequent WIs during medication preparation were by nurse colleagues followed by system failures due to missing medication

and equipment
Nurses preparing medications were interrupted by other nurses for personal matters 36% of the time and to exchange verbal reports

22% of the time
The most frequent WIs during medication administration were self-initiated and by patients during direct patient care activities
Nurses handled WIs immediately more than 98% of the time; the proportion of WIs handled immediately was similar during both

medication preparation and administration (98.8% and 97.6%, respectively)

A mean of 1 interruption per 3.2 drugs administered occurred during medication administration
When there was an increased number of drugs per medication pass for a single patient, the number of interruptions increased significantly

(P = .05).
Nurses intervened immediately when interrupted 96% of the time
Nurses perceived interruptions related to management of phone calls to be the highest risk for error during medication administration

Pooled data from 14 studies found WIs occurred at a rate of 6.7 interruptions per hour
The majority of interruptions were self-initiated by nurses administering medications during face-to-face interactions, occurred most

frequently during direct patient care, and were of short duration ranging from 45 sec to 1.2 min
Only 1 nonexperimental study documented the contribution of interruptions to medication errors with evidence of a significant association

(P = .01).

Continued

Table 2 Continued

Reference

Pape,22 2003

Nguyen et al,²5 2009

Anthony et al,27 20

Freeman et al,17 2013

Williams et al,26 2014

Sample/setting

Convenience sample of M/S unit
nurses were observed during a
single medication pass for assigned
patients in a 520-bed acute care
hospital in Texas

Forty-five nurses working on a 25-bed
M/S unit at an academic teaching
hospital in Northern California

The project was conducted in
partnership with a larger quality
improvement (QI) initiative spon-
sored by the Integrated Nurse
Leadership Program aimed at
improving patient safety and involved
7 hospitals in the San Francisco Bay28

Convenience sample of medical ICU
and surgical ICU nurses working in
a tertiary academic medical center
in Cleveland, Ohio

Convenience sample of 99 nurses in
a cardiac and thoracic surgical
step-down unit at a large, academic
medical center in the Midwest

Convenience sample of nurses
working in a surgical progressive
care unit (52 before intervention
and 48 after intervention)

Academic medical center in the
southeastern United States

Design/procedures

Quasi-experimental 3-group study
design including a comparison
group and 2 intervention groups

A validated instrument referred to
as the Medication Administration
Distraction Observation Sheet
(MADOS) was used to count
distractions

A longitudinal observational QI
project

One hundred medication passes
were observed before the interven-
tion and at 6 months and 1 year
after the intervention

Observational pilot project
A “no interruption zone” (NIZ) was

created by placing red tape around
all medication preparation areas to
signify that nurses were not to be
disturbed while preparing
medications

The number of interruptions before
and 4 weeks after the NIZ was
implemented were measured

Nurses observed were blinded to the
purpose of the study

Observational QI project.
A modified version of the MADOS

instrument was used to count the
number and type of interruptions

Observational study
Distractions and interruptions were

measured using the MADOS instru-
ment before and 2 months after
implementation of 5 evidence-
based safety strategies including
nursing staff education, use of a
medication safety vest, NIZ in
medication preparation areas,
signage on the unit and patient
rooms, and a resource tool for
scripting responses to interruptions

Purpose

Test the effectiveness of 2
interventions (“focused”
protocol and “medsafe”
protocol) to reduce distrac-
tions during medication
administration in comparison
to usual practice

Determine which distractors
are more predictive of nurses
being distracted during
medication administration

Evaluate whether a safety
initiative referred to as the
“Med Pass Time Out” was
effective and sustainable in
reducing medication
administration errors

Evaluate the effect of a NIZ on
the number of interruptions
during medication preparation

Determine whether implemen-
tation of a set of interventions
would reduce interruptions
during medication adminis-
tration

A secondary project goal was
to reduce medication errors

Interventions implemented
were previously described
in the literature, including
wearing a lighted lanyard
during medication adminis-
tration, triage of phone
calls, creating an NIZ in the
medication preparation
area, signage, and staff and
patient/family education

To evaluate the effectiveness
of implementing 5 evidence-
based safety strategies to
reduce distractions and
interruptions during
medication preparation

C. Strategies to limit interruptions

Findings/conclusions

Significant differences in the mean number of distractions were found between the comparison group and both intervention groups
(P < .001) as well as between the 2 intervention groups (“focused” protocol [P = .01] and “medsafe” protocol [P < .001])

The significant difference between the 2 intervention groups was attributed to use of a visible symbol that the nurse wore during medication
administration (a red vest with the lettering “Medsafe Nurse, Do Not Disturb”)

Conversation accounted for the majority (93%) of the variance in distractions, followed by interruptions by personnel (90%) and loud noises

Uninterrupted time increased from 81% to 99% of the time at 6 months and 1 year after implementation of the “Med Pass Time Out”
Medication errors decreased from 2% to 1% at 6 months and improvement was sustained at 1 year
No statistical analysis

The number of interruptions decreased by 40.9% (from 31.8% to 18.8%) after implementation of the NIZ (P = .03).
The proportion of interruptions initiated by nurses preparing medications (self-initiated interruptions) decreased from 25% to 0%

following implementation of the NIZ

Mean number of interruptions decreased from 3.29 to 1.18 during medication administration
Medication errors decreased by 28 events when compared with the same time period the year before
Patients, nurses, and patients’ family members represented the top 3 sources of interruptions before implementing interventions to

reduce interruptions; 1 month after implementation of the interventions, no interruptions were made by family members
No statistical analysis

Four types of distractions and interruptions decreased significantly after implementation of the safety strategies including those
initiated by (1) physicians, nurse practitioners, and physician assistants (P = .001), (2) phone calls and pages (P = .001), (3) other
personnel (P < .001), and (4) conversations unrelated to medication administration (P = .002)

Total reported adverse drug events decreased from 10 to 4 (60%)
Nurse were not found to be compliant with wearing the safety vest or using the resource tool when responding verbally to interruptions

but were compliant with use of signage and the NIZ when preparing medications

Continued

Table 2 Continued
Reference

Westbrook et al,3 2010

Hopkinson and
Jennings,29 2013

Raban and Westbrook,21
2014

Sample/setting

Convenience sample of 98 nurses
from 6 units at 2 major teaching
hospitals in Sydney, Australia

A total of 31 articles published
between 2001 and 2011 were
selected for analysis, including 12
that specifically examined nurse WIs
during medication administration

Studies were conducted in 7 countries,
including 14 studies conducted in
US acute care facilities

Ten studies meeting inclusion criteria
and published up to September 2012
were analyzed

Eight of the 10 studies were
published in North America

All studies used direct observation
for data collection, but studies were
not limited to the acute care setting

Design/procedures

Observational study
A total of 505 hours of observation

was conducted during an
18-month period

Systematic review
Most studies used a nonexperimental

design and involved direct observa-
tion methods for data collection

Systematic review
Studies included for analysis were

observational studies that reported
quantitative data on interruptions
or medication administration errors
with a pre- and postintervention
design or use of a comparison group

Studies included were not limited to
the acute care setting

Purpose

Examine the direct relation-
ship between WIs and
hospital medication
administration errors

Examine empirical evidence
from studies of nurse WIs
in the acute care setting

Assess evidence of the
effectiveness of interven-
tions aimed at reducing
interruptions during
medication administration
on

interruption and

medication administration
error rates

D. Contributions of interruptions to medication errors

Table 3 Nurses Uninterrupted Passing Medications Safely (NUPASS) guidelines
Before administering medications
1. Nurses update the charge nurse (CN) before administering medications if there are changes in patients’ status that affect

scheduled procedures or transport needs; otherwise, nurses simply place a colored magnet next to their name on the
assignment board (board in clear view at the front desk) to indicate that they are administering medications.

2. Nurses dock their phones just outside the medication room before entering to prepare medications. Docked phones are
programmed to forward all calls to the front desk.

3. Nurses don a yellow safety sash before leaving the medication room to administer medications.

After administering medications
1. Once medication administration is compete, nurses return their yellow safety sash to the medication room, pick up their

docked phone, remove the colored magnet from the assignment board, and check at the front desk for any new messages
recorded on a communication log.

General practice progressive cardiac care unit (PCCU) guidelines
1. Nurses perform hourly rounds on odd hours (corresponds with peak, scheduled medication times). Patient care assistants

(PCAs) perform hourly rounds on even hours.
2. Phone and face-to-face requests by family for patient information are screened for a password in accordance with the medical

centers’ policy for compliance with the Health Insurance Portability and Accountability Act (HIPAA) before contacting the
assigned nurse.

3. Nursing staff use key phrases to respond to nonemergent requests or inquiries: “For the safety of our patients,” we do not
interrupt the nurse while administering medications. Is there something I can help you with?

4. Unit secretaries refer requests/inquiries to the CN only in situations where they cannot triage or manage the communication
themselves.

5. Prespecified peak, scheduled medication administration times for “no interruption” except emergencies: 5 AM-7 AM,
8 AM-10 AM, and 8 PM-10 PM. Emergencies include imminent patient safety concerns, patients’ request for pain medica-
tion, emergency response to cardiac arrhythmia alert, need to communicate information only assigned nurse has specific
knowledge of in a critical event, rapid response, or cardiopulmonary arrest of assigned patient.

6. Signage on closed medication room door reminds staff that medication room is a “quiet zone.”
7. “No interruption zone” (NIZ) outlined on floor in the medication room next to the medication storage/delivery system.
8. “Daily Patient Care Activity Flowsheet”: Day-shift CN receives a brief report on each patient from the assigned nursing staff,

including scheduled procedures and patient transport needs for the next 24 hours before 8 AM daily during “huddle-up.”
This information is logged by the day-shift CN on a structured daily flow sheet and is updated by the evening and night
CNs on the basis of the corresponding shift reports by nursing staff to assist with coordination of patient care activities.

9. “Communication log”: used to document nonurgent messages while nurses are administering medications.
10. Patient/family education tool: written patient/family education provided on admission to help explain the pilot practice change.

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 27

failure, and uncontrolled atrial fibrillation. Patient care

was delivered by nursing staff including registered nurses

and certified nursing assistants referred to as patient care

associates (PCAs). The nurse to patient ratio was 1 to 4

on the day and evening shifts and 1 to 5 on the night shift.

The number of beds on each unit was from 36 to 46, and

the daily patient census was from 34 to 39. Technol-

ogy used to support the medication administration pro-

cess at the time of the pilot practice change included a

centralized medication storage system, computer phy-

sician order entry, and electronic medication administra-

tion record. Bar-code scanning of medications was not

available at the time of the pilot practice change. Geo-

graphic differences in the layout of the PCCUs included

the number of medication rooms and the number of

semiprivate versus private patient rooms. The project team

for the pilot practice change consisted of 5 bedside nurses

from the PCCUs, an advanced practice nurse, and a

nurse researcher.

Methods
Data Collection

The pilot practice change was conducted for 18

months. The baseline percentages of interruptions

and medication errors were measured in July 2009,

and these measures were repeated after implementa-

tion of the NUPASS guidelines in December 2010

(Figure 2). A convenience sample of nurses from each

PCCU was randomly observed during peak, scheduled

medication administration times. Nurses were aware

of being observed during data collection. Data collec-

tors used the following script to explain why they

were conducting observations during medication

administration:

We are conducting a quality improvement

project to identify opportunities to improve

patient safety during medication administra-

tion. All data [are] being collected anony-

mously and [do] not include the identity of

the nurses being observed during medica-

tion administration.

Observations were conducted during prespecified

times (5 AM – 7 AM, 8 AM – 10 AM, and 8 PM – 10 PM). The

number of observations conducted for each prespecified

time was based on the mean number of medications

scheduled during these peak administration times. The

project team staff nurses collected all data and observed

medication passes on PCCUs other than their own.

Two standardized data collection tools referred to as

the Medication Administration Accuracy Observation

f il d t ll d t i l fib ill ti P ti t d h d f i l

Findings/conclusions

Each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in medication errors
The frequency of interruptions during medication administration increased the risk of both the number and severity of medication errors
The estimated risk of a major error, defined as an error most likely to cause harm, permanent damage or death, doubled from 2.3%

with no interruption to 4.7% with 4 or more interruptions during administration of scheduled medications to a single patient

The evidence for reducing medication errors by limiting interruptions remains at the level of descriptive research because the majority
of projects were nurse-led QI projects

Interpretation of results was limited because of the different methods used for unit sampling, measuring, and defining interruptions

Five studies had statistically significant changes in the number of interruptions before and after implementation of a set of interventions;
interruptions decreased in 4 studies and increased in 1 study

The 3 studies that measured changes in medication error rates showed reductions, but all 3 studies implemented multiple interventions
besides those aimed at reducing interruptions

Weak evidence of the effectiveness of interventions intended to reduce interruptions and medication error rates exists primarily owing
to the small number of studies, and the lack of robust study design, appropriate statistical analyses, and small sample size

28 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org

Code Sheet and the Medication Administration Accuracy

Record Review Worksheet developed by the California

Nursing Outcomes Coalition (CALNOC) were modified

and adapted for use with written permission of CALNOC

(March 26, 2009). Before implementation of the pilot

practice change, an interrater reliability study involving

30 observations (10 per unit) was conducted to establish

agreement among trained data collectors and resulted

in 96% agreement. Operational definitions used for the

purposes of data collection during the pilot practice

project are listed in Table 4.

During observations, the data collectors were blinded

to the electronic medication orders to prevent confirma-

tion bias. The Medication Administration Accuracy

d h d h d d

Figure 1 Evidence-based practice (EBP) model.
Abbreviations: AHC, Advocate Health Care; APN, advanced practice nurse; IRB, institutional review board; NRC, Nursing Research Committee; PDSA, plan, do, study, act;
PICO, problem or population, intervention, comparison, and outcome.
Iowa Model adapted from Titler et al,30 with permission. ©University of Iowa.

Use the PICO Framework Worksheet (1)
to develop your PICO question.

Conduct Research

IRB Process

Identify Clinical Question/Problem (PICO)

Request to Investigate Practice

Complete Synthesis of
Evidence Worksheet

**Present to Council
(The council will depend

upon the type of project)

Pilot Practice Change

AHC Project Completion and Education
Planning Form (7)

Communicate Change

Monitor and Analyze Outcome Data

Nursing Research
Resource: AHC NRC
IRB Submission &
Review Process (9)

Complete the Practice Investigation Approval Form (2)
to assess a need for change and identify stakeholders.

Meet with librarian and/or APN and use the Evidence Matrix
(3) and Level of Evidence Reference (4) as tools for your
literature search. Critique and synthesize evidence using
the Evidence Synthesis Worksheet (5).

Refer to your site EBP or Research representative
to determine appropriate council

Yes

EVIDENCE-BASED PRACTICE (EBP) MODEL

NO- Cycle
complete
go back to
literature

Use the PDSA model to plan & conduct the pilot.
Resources: PDSA for Piloting Change Worksheet (6)

To implement project recommendations & conduct
education use the AHC Project Completion and
Education Planning Form (7)

Practice Change Communication

** Inform Shared Governance
Councils when needed

(ie, education and/or practice)

Is There
Sufficient
Evidence?

Adopt practice
change?

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 29

Observation Code Sheet is a flowsheet used to record

each medication administered during the observation

period and to tally each interruption observed during

the medication pass. Data collectors used the Medica-

tion Administration Accuracy Observation Code Sheet

to record each medication administered, including the

medication name, dose, route, and the time the medica-

tion was administered to the patient. Data collectors

were trained to record the reason for all interruptions

observed by using a free-text, narrative approach. The

project team planned to review the reasons for interrup-

tions after completion of the project and based on post-

hoc analysis, develop a scheme for categorizing the

sources of interruptions.

The Medication Administration Accuracy Record

Review Worksheet is a flowsheet used to identify

medication errors retrospectively by comparing medica-

tions administered during the observation period with

scheduled medication orders on the electronic medica-

tion administration record for the same time period.

Figure 2 Timeline for the Nurses Uninterrupted Passing Medications Safely (NUPASS) project’s pilot practice change.
Abbreviation: AACN, American Association of Critical-Care Nurses.

Attended AACN National
Teaching Institute, Chicago, Ilinois

(5/2009)
Measured % of interruptions and
medication errors after NUPASS
guideline implemented (12/2010)

Poster presentation at
AACN National

Teaching Institute, Boston,
Massachusetts (5/2012)

Measured % of interruptions and
medication errors before

NUPASS guideline
implemented (7/2009)

Pilot study (6/2009)

February
2010

November
2009

August
2011

November
2011

February
20

May
2012

February
2011

August
2009

May
2009

November
2010

May
2010

NUPASS guidelines
implemented (2/2010)

Initial internal presentation
of results (6/2011)

Remedial education for
intervention units (8/2010)

Analysis and interpretation
of results (5/2011)

Completed internal
presentation of results

(9/2011)

May
2011

August
2010

Table 4 Nurses Uninterrupted Passing Medications Safely (NUPASS) pilot practice change: operational definitions
Term
Interruption

Avoidable interruptions

Unavoidable interruptions

Medication error

Medication pass

Medication administration process

Definition
An event that halts the process of administering medication, causing the nurse to stop

the task of carrying out a step in the medication administration process and then return
to the medication administration process following disruption by another task or event.

Situations that could be managed by other staff members without risk of patient harm
while the nurse was administering medications. Examples include phone messages from
family members, responding to call lights, and nonemergent communication with staff in
other disciplines.

Situations that required immediate action by the nurse to maintain patient safety. Examples
include acute changes in patients’ status, responding to critical laboratory values, and
verifying and accessing information that may have a critical effect on patients’ outcomes
(eg, a question regarding the exact time a continuous intravenous infusion of heparin was
stopped before proceeding with a scheduled lumbar puncture).

A medication administered to the patient differently than ordered by the physician.

Administration of all medications to a single patient during a scheduled, peak administration time.

The process of administering medications, including medication preparation, administration,
and documentation.

30 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org

Following the observed medication passes, data col-

lectors used the Medication Administration Accuracy

Record Review Worksheet to reconcile the electronic

medication orders with the medications actually admin-

istered to the patients to identify medication errors.

The number and type of medication errors identified

were recorded on the data collection tool, including

wrong drug, dose, form, route, and technique and

omission of drug dose errors.

Communication Strategies
Once baseline data collection was complete on all 3

units, the project team trained the PCCU1 and PCCU2

nursing staff how to implement the NUPASS guidelines.

Staff members were trained to use communication scripts

to respond to nonemergent requests when nurses were

passing medications. The communication script simply

stated, “For the safety of our patients, the nurses are not

interrupted while passing medications. Is there some-

thing I can help you with?” Use of the phrase “for the

safety of our patients” was essential to avoid misconcep-

tions that the nurse was just “too busy” to speak to them.

The unit secretary managed most communication with

visitors and requests for clerical assistance from physi-

cians and other health care providers while the charge

nurse was responsible for addressing patient care

issues with phy-

sicians and

other care pro-

viders. The

nursing staff

was provided with operational definitions of emergen-

cies as part of the NUPASS guidelines; however, because

no guidelines address all situations, the members of the

nursing staff were coached to consider if a safety concern

existed before deciding whether or not to interrupt a

nurse during a medication pass.

The nurses and PCAs coordinated patient care

activities by alternating hourly patient care rounds to

ensure that the timing of nursing rounds corresponded

to the peak times for administering scheduled medications.

Purposeful, hourly rounding has been demonstrated to

decrease patients’ use of call lights and was a best prac-

tice established on the PCCUs before the pilot project

change.23 However, as part of the pilot practice change,

nurses wore a yellow safety sash during scheduled, peak

medication administration times as a visible sign that

they were passing medications and were not to be dis-

turbed. Before beginning the medication pass, nurses also

placed a colored magnet next to their name on the assign-

ment board to alert other care providers that they were in

the process of passing medications. Because the PCCU

assignment boards were in clear view from the centralized

nursing stations, this tactic provided another visible sign

to alert others of the medication pass. Once nurses were

done administering medications, they removed their yel-

low safety sash, picked up their docked phone, removed

the magnet from the assignment board, and checked with

the charge nurse for any logged messages or updates.

Educational Strategies
Unit staff, physicians, and other care providers hospital-

wide were educated on the pilot practice change, includ-

ing the purpose of the project and instructions for

communicating and coordinating care during scheduled,

peak medication administration times. Care providers

from numerous departments (pharmacy, rehabilitation,

nutrition, cardiodiagnostics, emergency, and transpor-

tation service) were educated in 6 months. Education

strategies included staff newsletters tailored to specific

departments, poster presentations, unit-based in-service

training programs, and presentations at scheduled staff

and physician meetings. Upon admission to PCCU1

and PCCU2, a patient-specific newsletter (Table 5) was

used to educate patients and their families about the

pilot project change.

Results
During the pilot practice change, 130 medication

passes were observed on the 3 PCCUs, including 64

medication passes before and 66 medication passes after

guideline implementation. During the 130 medication

passes, nurses were observed administering 631 medica-

tions: 316 medications before and 315 after guideline

implementation. The mean number of medications

administered per patient was 4.10, and the mean dura-

tion of medication passes was 11.69 minutes. Neither

the mean number of medication doses nor the duration

of medication passes differed significantly between units

before or after guideline implementation.

Interruptions
To answer the first question, the percentage of inter-

ruptions decreased significantly in 1 of the 3 PCCUs after

The project team staff nurses collected
all data and observed medication
passes on PCCUs other than their own.

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 31

implementation of the NUPASS guidelines. Interruptions

decreased from 23% to 4% (P < .001) in PCCU1 after imple-

mentation of the NUPASS guidelines. In comparison,

the percentage of interruptions did not change signifi-

cantly in PCCU2, and although the change was not sta-

tistically significant, the percentage increased in PCCU3

after guideline implementation (Table 6). Based on post-

hoc analysis, interruptions were categorized in 2 different

ways: (1) source of the interruption and (2) avoidable

versus unavoidable interruptions.

Four main sources of interruptions were identified:

(1) patient-related, (2) phone calls, (3) verbal (face-to-face

interaction), and (4) unavailability of resources (Figure 3).

Most of the decrease in interruptions after guideline

implementation was due to a 48% reduction in phone calls.

The second largest source of interruptions both before

and after implementation of the NUPASS guidelines

was the unavailability of resources. Of these, 85% were

because the nurse had to stop and get water or a cup

for the patient before administering medications.

In comparison, missing equipment and other supplies

accounted for only 15% of the interruptions in this cate-

gory. The majority of phone calls and verbal (face-to-face)

interruptions were related to patient care activities

including requests from patients, unit personnel, and

other care providers. Interruptions by physicians during

the pilot practice change accounted for only 7% of the

total interruptions. Patient-related sources of interruptions

Table 5 Patient medication safety newsletter
You may hear today:
“For the safety of our patients, we do not interrupt the nurses while they are administering medications. Is there something I can

assist you with?”

A team of nurses is conducting a project to improve patient safety. The purpose of the project is to increase patient safety by
limiting interruptions during medication administration.

Why is this project important? Numerous studies suggest that interruptions during medication administration contribute to
medication errors.

How are interruptions limited when the nurses are administering medications? Nurses will not take phone calls or respond
to inquiries from others including nursing staff, therapists, physicians, patients, and families when they are administering
medications EXCEPT for emergencies during these times:

8 to 10 AM
8 to 10 PM
5 to 7 AM

How will I know when the nurse is administering medications?

Nurses will wear a yellow safety sash to signify that they are administering medications and are not to be interrupted. Limiting inter-
ruptions allows the nurses to keep their attention focused on medication administration and the needs of the each patient who is
receiving medications.

What if I need to communicate with my nurse?
• The phone numbers of your nurse and patient care assistant (“PCA”) are posted on your communication board. You can call them

directly to avoid waiting for your call light to be answered.
• When your nurse is administering medications, his/her calls will be automatically forwarded to the front desk for further assistance.
• The nurse and the PCA take turns rounding at your bedside hourly to offer assistance so that your needs are met promptly.
• If you need help to the bathroom, with bathing, or need something to drink or eat, you can call your PCA.

Who can I talk to if I have more questions about the project? Your nurse will be able to answer most questions. Please also feel
free to direct any questions or comments to the Manager or Advanced Practice Nurse during their daily rounds. This project is a
team effort, and we need your help and support to make it a success!

Thank you from the project team!

Table 6 Interruptions before and after Nurses
Uninterrupted Passing Medications Safely (NUPASS) guide-

lines were implemented

Progressive
cardiac care unit
(PCCU)
PCCU1
(intervention unit)

PCCU2
(intervention unit)

PCCU3
(comparison unit)

Before
NUPASS

22/95 (23%)

25/118 (21%)

10/103 (10%)

After
NUPASS

5/113 (4%)

22/99 (22%)

15/103 (15%)

P
<.001

.46

.24

32 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org

did not differ before or after the implementation of the

NUPASS guidelines.

Avoidable interruptions decreased from 18 to 3 (83%)

in PCCU1 and from 19 to 9 (53%) in PCCU2 while avoid-

able interruptions in PCCU3 increased from 7 to 12

(71%) after implementation of the NUPASS guidelines

(Figure 4). Although PCCU2 did not show a statistically

significant decrease in the total percentage of interrup-

tions following implementation of the NUPASS guidelines,

the unit was successful in decreasing avoidable interrup-

tions by more than half. Unavoidable interruptions

decreased from 4 to 2 (50%) in PCCU1, increased from 6

to 14 (133%) in PCCU2 and increased from 1 to 2 (100%)

in PCCU3 after implementation of the NUPASS guidelines.

Medication Errors
To answer the second question, the percentage of

medication errors decreased in all 3 PCCUs after imple-

mentation of the NUPASS guidelines (Table 7). A statis-

tically significant decrease in the percentage of medication

errors was found in 1 of the 2 intervention units and in

the comparison unit. The percentage of medication

errors in PCCU1 decreased from 11% to 3% after the

guidelines were implemented (P = .02). Although the

percentage of medication errors in the second interven-

tion unit (PCCU2) decreased from 2% to 1%, the number

of observations conducted was not powered to demon-

strate a statistically significant change between such low

percentages of medication errors. An unanticipated find-

ing was a significant decrease in the percentage of medi-

cation errors (P = .01) in the comparison unit (PCCU3).

Discussion
Interruptions

Consistent with the findings of numerous pub-

lished studies, nurses observed during the pilot practice

change were frequently interrupted during medication

administration.6-8,11,12 In addition, results of the pilot

practice change support earlier reports that the majority

of interruptions during medication administration are

avoidable and may lead to adverse consequences for

patients.16,31 The greatest impact of implementing the

NUPASS guidelines was the significant decrease in avoid-

able interruptions, particularly those related to phone

Di i

Table 7 Medication errors before and after Nurses
Uninterrupted Passing Medications Safely (NUPASS)

guidelines were implemented

Progressive
cardiac care unit
(PCCU)
PCCU1
(intervention unit)
PCCU2
(intervention unit)
PCCU3
(comparison unit)
Before
NUPASS

10/95 (11%)

2/118 (2%)

9/103 (9%)

After
NUPASS

3/113 (3%)

1/99 (1%)

1/103 (1%)

P
.02

.57

.01

did diff b f f h i l i f h

Figure 3 Number of interruptions by source before and
after Nurses Uninterrupted Passing Medications Safely
(NUPASS) project.

N
o.

o
f i

nt
er

ru
pt

io
ns

Source

Patient
related

Before NUPASS After NUPASS

Phone
calls

Verbal UnknownResource
unavailable

10
5
0

Figure 4 Avoidable and unavoidable interruptions before
and after Nurses Uninterrupted Passing Medications
Safely (NUPASS) project.

N
o.
o
f i
nt
er
ru
pt
io
ns

Progressive cardiac care unit (PCCU)
PCCU1 PCCU2 PCCU3

Avoidable before NUPASS
Avoidable after NUPASS
Unavoidable before NUPASS
Unavoidable after NUPASS

16
14

12
20
10
8

6
4

2
0

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 33

calls. Successfully decreasing interruptions related to

phone calls was highly dependent on teamwork and

highlights the important role of support staff in priori-

tizing and managing phone calls during peak scheduled

medication administration times.

An important paradigm shift for PCCU nurses was

to assume accountability for interruptions, including

avoiding social chatter in the medication room and dele-

gating or deferring tasks when appropriate to main-

tain a concentrated focus on medication administration.

The pilot project team identified differences in unit cul-

ture, workflow demands throughout the 24-hour period,

visibility of leadership, and informal leadership support

on each shift as factors that may have influenced nurs-

ing staff buy-in and adherence to the NUPASS guidelines.

Adherence to the guidelines by physicians, other care

providers, and patients was greatly enhanced by educa-

tion and the use of key messages. The most important

message for gaining cooperation and support from phy-

sicians was that the practice change was to help “manage”

rather than limit communication among care providers.

The responses of patients and their families were

overwhelmingly positive when the pilot practice change

was introduced, and they often shared how impressed

they were that the staff took the patients’ safety so seri-

ously. However, the fact that the number of patient-

related interruptions remained the same before and

after implementation of the NUPASS guidelines sug-

gests the need to reinforce patient education about the

pilot project change throughout the hospital stay such as

signage in the patients’ rooms and verbal reminders.

Although no clinically significant difference was found

in unavoidable interruptions before and after implemen-

tation of the NUPASS guidelines in PCCU1 or PCCU3, a

large increase in unavoidable interruptions occurred in

PCCU2 after guideline implementation; that increase

was attributed to orientation and training of newly hired

nurses during this period.

Medication Errors
It is not clear why the percentage of medication

errors in PCCU2 was lower than in the other 2 units at

baseline. The only observable difference between units

was that PCCU2 has 2 centralized medication rooms

compared with only 1 such room on the other 2 PCCUs.

In addition, the finding that the percentage of medica-

tion errors decreased significantly after guideline

implementation in the comparison unit (PCCU3), inde-

pendent of the percentage of interruptions, highlights

that numerous factors besides interruptions affect

patient safety outcomes.

Sustainability of the Pilot Practice Change
The Institute of Medicine recommends that nurses

be observed periodically to measure actual medication

errors rather than relying completely on voluntary

reporting of medication errors.2 Observation methods

to measure medication errors are useful for overcoming

pitfalls of traditional event reporting, including underre-

porting of errors.32-35 However, direct observation to

measure interruptions and medication errors is time-

and resource-intensive because it requires trained data

collectors and coordination of data collecting activities.

A novel quality improvement approach used at Stanford

Health Care for ongoing measurement of interruptions

and medication errors shared by Elisa E. Nguyen (e-mail

communication, May 22, 2015) is to observe nurses admin-

istering medications as part of regularly scheduled hos-

pital prevalence

studies. Regard-

less of the method

used for collecting

interruption and

medication error

data, ongoing monitoring for quality improvement and

regular, timely feedback to nursing staff regarding mea-

sured outcomes is essential to promote a culture of safety

and sustain results in high-reliability organizations.

After the official project was completed, the

NUPASS project team was not able to continue the

quality improvement monitoring activities to evaluate

the sustainability of the outcomes associated with the

pilot practice change because of time constraints,

nursing staff turnover, and lack of funding. Lack of a

sustainability plan for this project resulted in a drift

back to former practice and is consistent with the find-

ings of Freeman and colleagues,17 who evaluated the

use of a similar set of strategies to limit interruptions in

a single progressive care unit. However, in July 2014, a

modified version of the pilot practice change was imple-

mented in all patient care units as a best practice with

the leadership support of the medical center’s chief nurse

executive. A major change in the guidelines is that the

yellow safety sash has been replaced by a hand-held

Decreasing interruptions was
highly dependent on teamwork
and highlights the important role
of support staff.

34 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org

bar-code scanner as a visible sign that the nurse is

administering medications and is not to be disturbed.

Limitations of the Pilot Practice Change
Although approximately one-third of the PCCU

nurses participated in the project, use of a convenience

sample of nurses limits the representativeness of the

sample. Second, observations were limited to 3 specialty

units at a single site, preventing generalization of the

findings to other patient populations and health care

settings. Third, because the nurses were aware that they

were being observed, they may have followed adminis-

tration safety practices more consistently, leading to

fewer medication errors (Hawthorne effect). Finally,

the comparison unit (PCCU3) was restructured after

the baseline data were collected for the pilot practice

change. The restructuring involved cohorting cardio-

vascular surgical patients at a lower nurse to patient

ratio; both of these factors limit the use of PCCU3 as

a comparison unit.

Last, for the purposes of this project, the definition

of medication errors was limited to administering medi-

cations as ordered by the physician. However, progres-

sive care nurses continuously make clinical judgments

about the appropriateness of carrying out medication

orders. These

judgments are

based on the

patient’s clini-

cal status,

relevant labo-

ratory data,

and contraindications related to risks of complications

associated with diagnostic and interventional proce-

dures. The critical thinking and decision-making pro-

cesses involved in making these judgments represent

important monitoring and surveillance activities nurses

use to keep patients safe regardless of the prescribed

medication order.

Conclusions
Results of the NUPASS pilot practice change demon-

strate that using evidence-based strategies to limit inter-

ruptions during medication administration in the

progressive cardiac care setting decreases avoidable

interruptions and promotes patient safety. Recognizing

medication administration as a high-risk activity is

critical to transforming the culture and engaging nursing

staff to promote the kind of teamwork necessary to limit

avoidable interruptions during medication administra-

tion. In this pilot practice change, we evaluated the

impact of limiting interruptions during medication

administration during scheduled, peak administration

times. The impact of limiting interruptions on medica-

tion errors during unscheduled administration of medi-

cations including as-needed medications and initiation

and titration of high-risk intravenous infusions (eg,

antiarrhythmic and inotropic agents) administered in

the progressive care setting warrants further study.

Although no “magic bullet” is available to prevent

medication administration errors, the outcomes of this

project support the use of evidence-based strategies to

limit interruptions during medication administration

as part of a comprehensive medication safety program.

Bedside nurses have little control over the physical lay-

out of the patient care unit, the nurse to patient ratio,

or access to technological advances to prevent medica-

tion errors; however, they can successfully affect the work

environment to promote patient safety with little or no

cost to the organization by adopting evidence-based

strategies to limit work interruptions during high-risk

activities such as medication administration. ��

Acknowledgments
The authors thank project team members Dawn Hart, RN, BSN, and Sue Glavin,
RN, MSN, FNP, ANCC-BC, for their dedication and commitment to the project,
Wendy Tuzik Micek, RN, PhD, NEA-BC, and Nancy Gaziano, BA, for their editorial
assistance, and Susan Massatt, RN, MA, CCRN, NEA-BC, and Lynn Hennessy, RN,
MS, MBA, NE, for their administrative support.

Financial Disclosures
None reported.

Now that you’ve read the article, create or contribute to an online discussion about
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d tmore
To learn more about patient safety in the critical care setting, read
“Safety Culture in Australian Intensive Care Units: Establishing a
Baseline for Quality Improvement” by Chaboyer et al in the American
Journal of Critical Care, March 2013;22:93-102. Available at www
.ajcconline.org.

References
1. Sculli GL, Fore AM, Neily J, Mills PD, Sine DM. The case for training

Veterans Administration frontline nurses in crew resource manage-
ment. J Nurs Admin. 2011;41(12):524-530.

2. Institute of Medicine. Action agenda for health care organizations. In:
Aspden P, Wolcott JA, Bookman JL, Cronenwett LR, eds. Preventing
Medication Errors: Quality Chasm Series. Washington, DC: National
Academies Press; 2007:221-265.

An important paradigm shift for PCCU
nurses was to assume accountability
for interruptions, avoiding social
chatter in the medication room and
delegating or deferring tasks when
appropriate.

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 35

3. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association
of interruptions with an increased risk and severity of medication
administration errors. Arch Intern Med. 2010;170(8):683-690.

4. Potter P, Wolf L, Boxerman S, Grayson D. Understanding the cognitive
work of nursing in the acute care environment. J Nurs Adm. 2005;
35(7-8):327-335.

5. Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing
care. Jt Comm J Qual Patient Saf. 2010;36(3):126-132.

6. Kreckler S, Catcchople K, Bottomley M, Handa A, McCulloch P. Inter-
ruptions during drug rounds: an observational study. Br J Nurs. 2008;
17(21):1326-1330.

7. Biron AD, Lavoie-Tremblay M, Loiselle CG. Characteristics of work
interruptions during medication administration. J Nurs Scholarsh. 2009;
41(4):330-336.

8. Palese A, Sartor A, Costaperaria G, Bresadola V. Interruptions during
nurses’ drug rounds in surgical wards: observational study. J Nurs Manag.
2009;17(2):185-192.

9. Cornell P, Riordan M. Barriers to critical thinking: workflow interruptions
and task switching among nurses. J Nurs Admin. 2011;41(10):407-414.

10. Clark AP, Flanders S. Interruptions and medication errors. Clin Nurse
Spec. 2012;26(5):239-243.

11. Eisenhower LA, Hurley AC, Dolan N. Nurses’ reported thinking during
medication administration. J Nurs Scholarsh. 2007;39(1):82-87.

12. Relihan E, O’Brien V, O’Hara S, Sike B. The impact of interventions to
reduce interruptions and distractions to nurses during mediation
administration. Qual Saf Health Care. 2010;19(5):52-57.

13. Biron AD, Loiselle CG, Lavoie-Tremblay M. Work interruptions and
their contributions to medication administration errors: an evidence
review. Worldviews Evid Based Nurs. 2009;6(2):70-86.

14. Rivera J, Karsh BT. Interruptions and distractions in healthcare: review
and reappraisal. Qual Saf Health Care. 2010;19(4):304-312.

15. Tomietto M, Sartor A, Mazzocoli E, Palese A. Paradoxical effects of a
hospital-based, multi-intervention programme aimed at reducing medi-
cation round interruptions. J Nurs Manag. 2012;20(3):335-343.

16. Buchini S, Quattrin R. Avoidable interruptions during drug administra-
tion in an intensive rehabilitation ward: improvement project. J Nurs
Manag. 2012;20(3):326-334.

17. Freeman R, McKee S, Lee-Lehner B, Pesenecker J. Reducing interruptions
to improve patient safety. J Nurs Care Qual. 2013;28(2):176-185.

18. Yoder M, Schadewald D, Dietrich K. The effect of a safe zone on nurse
interruptions, distractions, and medication administration errors. J Infus
Nurs. 2015;38(2):140-151.

19. Popescu A, Currey J, Botti M. Multifactorial influences on and deviations
from medication administration safety and quality in the acute medical/
surgical context. Worldviews Evid Based Nurse. 2011;8(11):15-24.

20. Hedberg B, Larsson US. Environmental elements affecting the decision-
making process in nursing practice. J Clin Nurs. 2004;13(3):316-324.

21. Raban MZ, Westbrook JI. Are interventions to reduce interruptions and
errors during medication administration effective? A systematic review.
BMJ Qual Saf. 2014;23(5):414-421.

22. Pape TM. Applying airline safety practices to medication administration.
MedSurg Nurs. 2003;12(2):77-93.

23. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients’
call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-70.

24. Conrad C, Fields W, McNamara T, Cone M, Atkins P. Medication room
madness: calming the chaos. J Nurs Care Qual. 2010;25(2):137-144.

25. Nguyen EE, Connolly PM, Wong V. Medication safety initiative in
reducing medication errors. J Nurs Care Qual. 2010;25(3):224-230.

26. Williams T, King, MW, Thompson JA, Champagne MT. Implementing
evidence-based medication safety interventions on a progressive care
unit. Am J Nurs. 2014;114(11):53-62.

27. Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. No interruptions
please: impact of a no interruption zone on medication safety in inten-
sive care units. Crit Care Nurs. 2010;30(3):21-29.

28. Kliger J, Blegen MA, Gootee D, O’Neil E. Empowering frontline nurses:
a structured intervention enables nurses to improve medication admin-
istration accuracy. Jt Comm J Qual Patient Saf. 2009;35(12):604-612.

29. Hopkinson SG, Jennings BM. Interruptions during nurses’ work: a
state-of-the-science review. Res Nurs Health. 2013;36(1):38-53.

30. Titler MG, Klieber C, Steelman VJ, et al. The Iowa model of evidence-
based practice to promote quality care. Crit Care Nurs Clin North Am.
2001;13(14):497-509.

31. Hall L, Ferguson-Pare M, Peter E, et al. Going blank: factors contribut-
ing to interruptions to nurses’ work and related outcomes. J Nurs
Manag. 2010;18(8):1040-1047.

32. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of
methods for detecting medication errors in 36 hospitals and
skilled-nursing facilities. Am J Health-Sys Pharm. 2002;59(5):436-445.

33. Ulamino VM, O’Leary-Kelly C, Connolly PM. Nurses’ perception of
causes of medication errors and barriers to reporting. J Nurs Care Qual.
2007;22(1):28-33.

34. Brady AM, Malone AM, Fleming S. A literature review of the individual
and systems factors that contribute to medication errors in nursing
practice. J Nurs Manag. 2009;17(6):679-697.

35. Donaldson N, Aydin C, Foley M. Improving medication administration
safety: using naïve observations to assess practice and guide improve-
ments in process and outcomes. J Healthc Qual. 2014;36(6):58-68.

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Running head:

TOPIC SEARCH STRATEGY 2

Topic Search Strategy

Clinical Question

Medical errors are a serious healthcare issue, which is a leading cause of death in the US. According to Pham et al. (2012), about 98,000 deaths that occur in the Us every year is as a result of medical errors in the healthcare settings. The causes of this problem are difficult to uncover, and when they are found, it is also difficult to provide a solution that minimizes its recurrence. Nurses play a crucial role in enhancing patient safety through monitoring and interception of medical errors that may cause harm to the patients. The most common forms of medical errors reported occur in the process of medication administration, and they include documenting and monitoring patient’s condition, prescription, dispensing, and transcription errors (Hayes et al., 2015). Medication administration is prone to medical errors, and interruptions in this process increase the likelihood of occurrence of errors. Interruptions lead to errors that increase the risk of patient harm, the length of hospital stay, and healthcare costs; thus, there is a need for safety intervention strategies to reduce interruptions.

Studies have revealed that nurses have little time to pay attention to medication administration because of frequent and short interruptions. According to Flynn et al. (2016), the common source of interruption among the nursing staff is seeking assistance or information about patient care from other healthcare providers. Other forms of interruptions include frequent phone calls, conversations unrelated to medications, and inaccessible medical supplies and equipment. Besides, Hayes et al. (2015) state that nurses engage in medication administration for about 16 to 40% of their time. Thus, the way interruptions are managed in the medication administration process impacts the ability of the nurses to deliver safe and effective care to the patients. On the other hand, the study by Cheragi et al. (2013) indicated that 64.55% of the nurses reported medication errors, while 31.37% of them are on the verge of a medication error. The study also reported a mean incidence of medication errors to be 7.4 for each nurse in three months. The findings from these studies indicate that medication errors often occur in the nursing practice due to interruptions and suggest the need to utilize safety interventions to limit interruptions, especially during medication administration.

Elimination of medication errors was the source of the PICO question, “For the nurses taking care of patients in healthcare settings, how can safety interventions as compared to no intervention reduce medication errors?” This paper aims at finding out how safety interventions can help in reducing medication errors, which is common among nurses during medication administration.

Search Strategy

The strategy utilized when looking for an article was to get an article that has a high level of evidence and relevant to the PICO question. Using the Chamberlain University Library, I search through various databases, including PubMed and Medline. The search was achieved by turning the PICO question into a research topic. For instance, the research topic used is “Safety interventions to reduce medication errors in nursing practice.” The search terms that I used to search for the article that answers the PICO question include medication errors, safety interventions, nursing errors in healthcare settings, and medication administration. The initial search using the key words gave 543 results. I did an advanced search by putting limits on my search, such as searching for articles published from 2015 to 2020, having full text available, and peer-reviewed. This criterion gave me a more narrowed search that is appropriate for this assignment and gave 17 results. From the 17 results, I chose one article, which is a study by Flynn et al. (2016). This article has a manageable number of pages; hence, information can be extracted within a short time. Also, the article is rich in information that helps answer the PICO question.

Level of Evidence

The type of research question being asked is a prognosis question. A prognosis question determines a course over time (safety intervention) and provides a guess to the expected outcome (reduce the medication errors). The question is asking the effectiveness of safety interventions in the reduction of medication errors in nursing care in healthcare settings. Various safety interventions can be taken by nurses to reduce medication errors. This question can be answered through cohort studies because it involves participants making observations before coming up with an outcome in question. Flynn et al. (2016) noted that medication errors occur in medication administration as a result of interruptions, and the implementation of evidence-based strategies aiming to reduce interruptions will promote patient safety. This is a mixed-method study conducted through direct observation of nurses on two progressive cardiac care units. The quantitative data gathered in the research provide accurate evidence on the incidences of medication errors and the effectiveness of the safety interventions. Based on the evidence hierarchy, this study by Flynn et al. (2016) provides level 5 evidence, and thus, they are becoming more reliable.

References

Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research, 18(3), 228–231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748543/#:~:text=While%20a%20great%20number%20of

Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration. Critical Care Nurse, 36(4), 19–35. https://doi.org/10.4037/ccn2016498

Hayes, C., Jackson, D., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. Journal of Clinical Nursing, 24(21–22), 3063–3076. https://doi.org/10.1111/jocn.12944

Pham, J. C., Aswani, M. S., Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P. J. (2012). Reducing Medical Errors and Adverse Events. Annual Review of Medicine, 63(1), 447–463. https://doi.org/10.1146/annurev-med-061410-121352

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