NUR 683 Module 9 Final Project Example

Protecting the Medication Pass: An Interruption and Barcode Scanning Bundle to Reduce Administration Errors on a Telemetry Unit

[Student Name]

Southern New Hampshire University

NUR 683: Patient Safety and Quality Capstone

Module Nine Final Project

[Instructor Name]

[Date]

Protecting the Medication Pass: An Interruption and Barcode Scanning Bundle to Reduce Administration Errors on a Telemetry Unit

Abstract

Medication administration is the last defense before an error reaches a patient, and it is routinely broken up by calls, alarms and questions. On a 34-bed cardiac telemetry unit in a composite community hospital, two weeks of direct observation of 412 administrations found 9.2 clinical errors per 100 doses, interruptions in 52% of administrations and scanning of both patient and drug in 79%, while the unit filed only about four error reports a month. The proposed bundle has four parts: a quiet zone for preparing doses, rerouted calls while the morning pass is under way, equipment and label fixes that make scanning dependable and a fairer way of responding when errors occur. Evaluation uses weekly observation, monthly trigger tool review and control charts, with balancing and culture measures and a sustainability plan.

Background and Problem

Leaders at Ridgeview Memorial had judged the telemetry floor safe because it generated few medication error reports. When the student and a pharmacist watched medication passes on all shifts, a different picture emerged. Wrong-time doses of time-critical drugs, omissions and wrong doses were the most frequent errors, and three involved insulin or heparin. More than a fifth of administrations skipped a procedural step such as confirming identity. Errors clustered in the morning pass, when interruptions were most frequent, and scanning was weakest in rooms lacking a wall-mounted scanner.

The gap between reports and observation reflects both the limits of voluntary reporting and a recent disciplinary response to a self-reported insulin error, after which reports fell. The unit therefore had a hidden problem and a culture that kept it hidden.

Safety Science Framing

The project adopts a systems view of error. Analysis with the SEIPS work system model traced errors to interacting conditions: a medication room beside the nurses' station, dense morning tasks, scanners in only half the rooms, smudging wristbands and staffing without protected time. Reason's distinction between frontline slips and the latent conditions behind them explains why retraining individuals would leave the risk unchanged. A prospective failure mode analysis of barcode administration identified six high-hazard failure modes, including scanning a spare wristband kept on a cart and scanning a dose after giving it.

Evidence Synthesis

Three questions shaped the evidence review. On whether interruptions raise error risk, Westbrook et al. (2010) observed thousands of doses and found that each added interruption increased both procedural failures and clinical errors, with serious error risk rising as interruptions accumulated. On whether interventions reduce interruptions, Raban and Westbrook (2014) found that most studies of vests, signs, protected areas and education reported fewer interruptions, and Westbrook et al. (2017) confirmed a reduction against control wards in a cluster randomized feasibility trial, though nurses found vests burdensome. On whether errors fall as a result, the evidence is weak because few studies were designed to detect it.

Barcode scanning offers a stronger technical defense. Poon et al. (2010) found that barcode verification with an electronic administration record substantially reduced administration errors and potential adverse drug events, but only when scanning was performed at the bedside for every dose. Koppel et al. (2008) showed that workarounds arise from unreadable labels, failing equipment and time pressure, which means that raising scanning rates requires fixing those causes rather than exhorting staff.

The Bundle

The bundle has four components. First, a marked zone around the medication room and dispensing cabinet will be designated for uninterrupted preparation, with a sign at eye level and an agreement among all staff, including managers and physicians, not to interrupt a nurse there except for emergencies. Second, during the morning pass from 8:30 to 10:00, phone calls and routine questions will be routed to the unit secretary and a resource nurse, and nurses will use a brief script to defer non-urgent requests. Third, every room will have a wall-mounted scanner, spare wristbands will be removed from carts, durable label stock will replace smudging bands, wrong-dose alerts will become hard stops and wireless boosters will cover weak spots. Fourth, the unit will replace automatic discipline for high-alert errors with a just culture algorithm that matches the response to the kind of behavior involved, consoling slips, coaching shortcuts and reserving sanctions for recklessness.

The bundle avoids vests, drawing on reports of their poor acceptability, and preserves a clear route for urgent interruptions, since a new arrhythmia on telemetry cannot wait.

Implementation

The bundle will be introduced over eight weeks. Scanner installation, wristband stock and alert redesign come first, because they remove the causes of workarounds. The protected zone and call redirection follow, tested first on day shift for two weeks and then extended. Staff learn the bundle through brief sessions at shift huddles plus a single-page guide, and a champion on each shift supports colleagues. The nurse manager, pharmacy director and a hospitalist sponsor have agreed to model the no-interruption rule themselves, which staff identified as the change most likely to make it credible.

Evaluation

Measurement repeats the baseline method. Two observers will watch 60 administrations a week, stratified by shift, after confirming that they classify errors consistently. Twenty discharged records a month will undergo trigger tool review for adverse drug events. Each measure is charted, as recommended by Benneyan (2003), with a control chart suited to its data type: p charts for the percentage of administrations interrupted and fully scanned, u charts for the two error rates, one from observation and one from chart review, and a g chart for administrations between high-alert errors. Control limits come from the baseline weeks and stay fixed, so post-bundle data are judged against prior performance. Balancing measures are morning pass duration and call light response time, and culture is measured with survey items and the Safety Organizing Scale at baseline and six months.

Table 1. Targets at Six Months

Note. A rise in reports is treated as a sign of trust, not of worse care.

Sustainability

Ownership passes to shift champions, the charge nurse and the nurse manager, with pharmacy and biomedical engineering responsible for equipment. A brief shift-opening safety discussion will review near misses and scanner faults. Observation will drop to 20 administrations a week after six months but continue. The unit practice council will rate the unit twice a year on leadership, culture and improvement maturity, and the bundle will be taught in orientation.

Limitations

The evaluation is a single-unit time series without concurrent controls, so hospital-wide changes could influence results. Observation may change behavior, although the same method before and after keeps that effect constant. The bundle combines several components, so their separate contributions cannot be known. And because evidence linking fewer interruptions to fewer errors is weak, the project may reduce interruptions without a detectable change in errors; that result would itself be useful to report.

Conclusion

This capstone shows the core competencies of the patient safety and quality track: measuring a hidden problem honestly, analyzing it as a system, grading the evidence, designing an intervention that fixes causes rather than people and planning evaluation able to distinguish change from noise. Protecting the medication pass is a modest intervention with a clear rationale, and the measurement plan ensures that whatever happens, the unit will learn from it.

References

Benneyan, J. C. (2003). Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care, 12(6), 458-464. https://doi.org/10.1136/qhc.12.6.458

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115

Raban, M. Z., & Westbrook, J. I. (2014). Are interventions to reduce interruptions and errors during medication administration effective? A systematic review. BMJ Quality & Safety, 23(5), 414-421. https://doi.org/10.1136/bmjqs-2013-002118

Westbrook, J. I., Li, L., Hooper, T. D., Raban, M. Z., Middleton, S., & Lehnbom, E. C. (2017). Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: A cluster randomised controlled feasibility study. BMJ Quality & Safety, 26(9), 734-742. https://doi.org/10.1136/bmjqs-2016-006123

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690. https://doi.org/10.1001/archinternmed.2010.65