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Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses' Medication Administration Processes and Systems (the MAPS Study).

McLeod M, Barber N, Franklin BD - PLoS ONE (2015)

Bottom Line: However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses' inherent behaviour; we grouped these behaviours into 'task focused', and 'patient-interaction focused'.We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.

View Article: PubMed Central - PubMed

Affiliation: The Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, United Kingdom, and the Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom.

ABSTRACT

Context: Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.

Aim: To identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions.

Methods: We used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures.

Findings: Overall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses' inherent behaviour; we grouped these behaviours into 'task focused', and 'patient-interaction focused'. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a 'double-checker'.

Conclusions: We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.

No MeSH data available.


Related in: MedlinePlus

Spaghetti diagram showing changes in travel pattern of one nurse during a ‘two-nurse’ evening drug round at site C (map of ward not drawn to scale).At site C, two nurses typically worked together on the drug round to administer medications to all patients; one nurse ‘caller’ and one nurse ‘runner’. The diagram shows the path of travel by the nurse ‘caller’ who initially stayed with the drug trolley: she used the laptop attached to the drug trolley to access the patient’s electronic medication administration record, called out doses to the ‘runner’ to retrieve medications from the bedside medication locker and prepared some doses from the drug trolley. After preparing medicines for the patient in room 6, the nurse caller went ‘ahead’ while the nurse runner remained to administer the doses; this process was repeated whenever a patient required assistance to take the medicines and led to a ‘single-nurse’ drug round for parts of the remaining round. During the drug round, the nurse caller went to the nurse base station twice (to retrieve a patient‘s folder to check oxygen saturation and to retrieve another patient’s folder for paper warfarin medication order) and treatment room once (to retrieve medication from the fridge). S03, site code; DR045, drug round code; N34 and N31, nurse codes.
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pone.0128958.g005: Spaghetti diagram showing changes in travel pattern of one nurse during a ‘two-nurse’ evening drug round at site C (map of ward not drawn to scale).At site C, two nurses typically worked together on the drug round to administer medications to all patients; one nurse ‘caller’ and one nurse ‘runner’. The diagram shows the path of travel by the nurse ‘caller’ who initially stayed with the drug trolley: she used the laptop attached to the drug trolley to access the patient’s electronic medication administration record, called out doses to the ‘runner’ to retrieve medications from the bedside medication locker and prepared some doses from the drug trolley. After preparing medicines for the patient in room 6, the nurse caller went ‘ahead’ while the nurse runner remained to administer the doses; this process was repeated whenever a patient required assistance to take the medicines and led to a ‘single-nurse’ drug round for parts of the remaining round. During the drug round, the nurse caller went to the nurse base station twice (to retrieve a patient‘s folder to check oxygen saturation and to retrieve another patient’s folder for paper warfarin medication order) and treatment room once (to retrieve medication from the fridge). S03, site code; DR045, drug round code; N34 and N31, nurse codes.

Mentions: Specific configurations (location and arrangement of human and material resources) and features (characteristics, interpretability, and pre-conditions for use) of structure-related aspects [37] of the medication system acted as a physical constraint on some drug round tasks. Such structure-related aspects increased medication safety in some cases, but contributed to interruptions, distractions, impaired workflow, and medication problems in others (Table 2, Figs 2 to 5).


Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses' Medication Administration Processes and Systems (the MAPS Study).

McLeod M, Barber N, Franklin BD - PLoS ONE (2015)

Spaghetti diagram showing changes in travel pattern of one nurse during a ‘two-nurse’ evening drug round at site C (map of ward not drawn to scale).At site C, two nurses typically worked together on the drug round to administer medications to all patients; one nurse ‘caller’ and one nurse ‘runner’. The diagram shows the path of travel by the nurse ‘caller’ who initially stayed with the drug trolley: she used the laptop attached to the drug trolley to access the patient’s electronic medication administration record, called out doses to the ‘runner’ to retrieve medications from the bedside medication locker and prepared some doses from the drug trolley. After preparing medicines for the patient in room 6, the nurse caller went ‘ahead’ while the nurse runner remained to administer the doses; this process was repeated whenever a patient required assistance to take the medicines and led to a ‘single-nurse’ drug round for parts of the remaining round. During the drug round, the nurse caller went to the nurse base station twice (to retrieve a patient‘s folder to check oxygen saturation and to retrieve another patient’s folder for paper warfarin medication order) and treatment room once (to retrieve medication from the fridge). S03, site code; DR045, drug round code; N34 and N31, nurse codes.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4476704&req=5

pone.0128958.g005: Spaghetti diagram showing changes in travel pattern of one nurse during a ‘two-nurse’ evening drug round at site C (map of ward not drawn to scale).At site C, two nurses typically worked together on the drug round to administer medications to all patients; one nurse ‘caller’ and one nurse ‘runner’. The diagram shows the path of travel by the nurse ‘caller’ who initially stayed with the drug trolley: she used the laptop attached to the drug trolley to access the patient’s electronic medication administration record, called out doses to the ‘runner’ to retrieve medications from the bedside medication locker and prepared some doses from the drug trolley. After preparing medicines for the patient in room 6, the nurse caller went ‘ahead’ while the nurse runner remained to administer the doses; this process was repeated whenever a patient required assistance to take the medicines and led to a ‘single-nurse’ drug round for parts of the remaining round. During the drug round, the nurse caller went to the nurse base station twice (to retrieve a patient‘s folder to check oxygen saturation and to retrieve another patient’s folder for paper warfarin medication order) and treatment room once (to retrieve medication from the fridge). S03, site code; DR045, drug round code; N34 and N31, nurse codes.
Mentions: Specific configurations (location and arrangement of human and material resources) and features (characteristics, interpretability, and pre-conditions for use) of structure-related aspects [37] of the medication system acted as a physical constraint on some drug round tasks. Such structure-related aspects increased medication safety in some cases, but contributed to interruptions, distractions, impaired workflow, and medication problems in others (Table 2, Figs 2 to 5).

Bottom Line: However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses' inherent behaviour; we grouped these behaviours into 'task focused', and 'patient-interaction focused'.We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.

View Article: PubMed Central - PubMed

Affiliation: The Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, United Kingdom, and the Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom.

ABSTRACT

Context: Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.

Aim: To identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions.

Methods: We used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures.

Findings: Overall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses' inherent behaviour; we grouped these behaviours into 'task focused', and 'patient-interaction focused'. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a 'double-checker'.

Conclusions: We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.

No MeSH data available.


Related in: MedlinePlus