Innovative approaches to reducing nurses' distractions during medication administration.
BACKGROUND
Contributing factors to medication errors include distractions, lack of focus, and failure to follow standard operating procedures. The nursing unit is vulnerable to a multitude of interruptions and distractions that affect the working memory and the ability to focus during critical times. Methods that prevent these environmental effects on nurses can help avert medication errors.


METHODS
A process improvement study examined the effects of standard protocols and visible signage within a hospital setting. The project was patterned after another study using similar techniques. Rapid Cycle Testing was used as one of the strategies for this process improvement project. Rapid Cycle Tests have become a part of the newly adopted Define, Measure, Analyze, Improve, and Control steps at this particular hospital.


RESULTS
As a result, a medication administration check-list improved focus and standardized practice. Visible signage also reduced nurses' distractions and improved focus.


CONCLUSIONS
The results provide evidence that protocol checklists and signage can be used as reminders to reduce distractions, and are simple, inexpensive tools for medication safety.
Pape
Tess M
TM
Quality Coordinator, University Health System, San Antonio, Texas, USA.
Guerra
Denise M
DM
Muzquiz
Marguerite
M
Bryant
John B
JB
Ingram
Michelle
M
Schranner
Bonnie
B
Alcala
Armando
A
Sharp
Johanna
J
Bishop
Dawn
D
Carreno
Estella
E
Welker
Jesusita
J
D000328:Adult; D001288:Attention; D001291:Attitude of Health Personnel; D002985:Clinical Protocols; D006804:Ergonomics; D005260:Female; D019983:Guideline Adherence / Q000592:standards; D006184:Habits; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007400:Interprofessional Relations; D008123:Location Directories and Signs; D008297:Male; D008508:Medication Errors / Q000379:methods / Q000451:nursing / Q000517:prevention & control*; D008568:Memory; D008875:Middle Aged; D015403:Nursing Evaluation Research; D009741:Nursing Staff, Hospital / Q000193:education / Q000458:organization & administration / Q000523:psychology; D015279:Organizational Culture; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D017751:Safety Management / Q000458:organization & administration*; D011795:Surveys and Questionnaires; D013997:Time Factors; D017749:Total Quality Management / Q000458:organization & administration