The Journal of Continuing Education in Nursing Vol. 36 No. 3 May/June 2005
By Tess M. Pape, PhD, MSN, BSN, RN; Denise M. Guerra, BSN, RN; Marguerite Muzquiz, MSN, RN, BC; John B. Bryant, RN, BSN; Michelle Ingram, BSN, RN; Bonnie Schranner, MSN, RN; Armando Alcala, RN; Johanna Sharp, MSN, RN; Dawn Bishop, MSN, RN; Estella Carreno, RN; Jesusita Welker, RN
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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 checklist improved focus and standardized practice. Visible signage also reduced nurses’ distractions and improved focus.
CONCLUSION
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.
AUTHORS
At the time the article was written, Dr. Pape was Quality Coordinator, University Health System, San Antonio, Texas. She is currently Assistant Professor, Patty Hanks Shelton School of Nursing, a Consortium of Abilene Christian, Hardin Simmons, and McMurray Universities, Abilene, Texas. Ms. Guerra is Staff Nurse, Ms. Muzquiz is Clinical Educator, Mr. Bryant is Senior Analyst, Risk Management, Ms. Ingram is Administrative Director, Quality and Process Improvement, Ms. Schranner is Director, Clinical Education, Mr. Alcala is Staff Nurse, Ms. Sharp is Clinical Educator, Ms. Bishop is Clinical Educator, Ms. Carreno is Charge Nurse, and Ms. Welker is Staff Nurse, University Health System, San Antonio, Texas.
Address correspondence to Tess M. Pape, PhD, MSN, BSN, RN, CNOR Assistant Professor, Patty Hanks Shelton School of Nursing, 2149 Hickory, Abilene, TX 79601.
Original text National Institutes of Health (NIH)