Chang Proposal - Milestone Essay

Pages: 7 (3361 words)  ·  Bibliography Sources: 6  ·  File: .docx  ·  Level: College Senior  ·  Topic: Health - Nursing

Important studies from each of these categories are discussed below.

Westbrook, et al. (2010) controlled for the work status and experience of nurses in their study on the association of interruptions with increased risk and severity of medication administration errors. While nursing experience and status were not found to be related to risk of clinical errors, work status was related, with part-time nurses had lower rates of procedural error (Westbrook, et al., 2010). Westbrook's (2009) research found that experienced nurses tended to be confident in their ability to recognize patients, but this recognition factor did not mean that the nurses were referring to the correct patient chart. An intervention strategy that reduced this source of medication-patient identity error from 17.4% to 82.4% was introduced by Franklin, et al. (2007) with the use of barcodes for patient medications.

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O'Brien (2010) found that changing the environment and communicating with stakeholders reduced the chance of medication administration errors. Operating room staff receives additional training in the management of distraction and a range of safety-related psychological skills (Mitchell and Flin, 2008). Recognition of the potential positive impact of standardized procedures and explicit training for dealing with interruptions and ensuring accurate administration of medication to patients resulted in the study by Hughes and Blegen (2008), in which the researchers created and evaluated an evidence-based medication handbook for nurses. Craig, et al. (2013) found that the number of overall interruptions declined when nurses wore a white vest worn during medication administration and imprinted with the words: "Please do not interrupt while passing medications." Relihan, et al. (2010) developed and tested a multifactorial set of interventions in a 1000-bed teaching hospital; the results showed a significant reduction in the interruption / distraction rate for five of 11 categories evaluated.

Step 4: Design Practice Change

Essay on Chang Proposal - Milestone #4 Assignment

The proposed practice change will be a multifactorial intervention that includes these important prongs: 1) Establishment of a distraction free zone for the preparation and administration of medication; 2) during medication rounds, nurses administering medications will wear disposal (red) sashes or vests to signal that they are not to be interrupted without unavoidable substantive cause; 3) use of a checklist that ensures the medication administration system is ready for the imminent medication round; 4) educational sessions with nursing staff and other stakeholders; 5) briefing -- where appropriate -- and the provision of explanatory brochures to patients; and 6) establishing a committee to address the practice problem locally "by encouraging the generation, trial, and iterative development of solutions directly by the nursing workforce" as recommended by Young and McClean (2008).

Step 5: Implement and Evaluate the Change in Practice

The change of practice will be driven by the content provided through the educational sessions with staff. The fundamental goal of the practice change is to reduce medication administration errors by improving staff awareness of the practice problem, establishing new behaviors to safeguard the change of practice, and to standardize clinical actions in order to facilitate the collection of data related to the fidelity of implementation and the reduction in the error rate of medication errors.

Implement & Evaluation Plan

The educational sessions will be conducted with nursing staff as part of the shift pass-down, as orientation of newly hired staff, and as a component of the routine staff training periodically conducted with teams. A special educational session will be conducted within two weeks of the change plan completion and approval. The checklist that will guide nursing staff to head off system issues will initially be based on the recommendations of Relihan, et al. (2010), and includes items such as: 1) Ensuring the medication trolley is stocked with any needed supplies prior to each medication round; 2) announcing the commencement of a medication round to colleagues; 3) instructing nursing students and naive observers to withhold comment or questions that are not directly impactful of the administration of medication; 4) donning the agreed upon signal apparel (red vest or sash) when preparations have been made; 5) closing doors and using "Do Not Disturb" signage on access doors where appropriate; 6) avoiding the initiation of unrelated communication with others during the medication round; 7) directing any interrupters to colleagues who are not administering medication; and, 8) addressing all instances of missing medications at one time -- at the end of the medication round (Relihan, et al., 2010).

All staff will participate in a baseline data collection process prior to implementation of the plan. To collect sentiment, awareness, and practice data from nursing staff, a survey will be administered every six months. The survey design will address the nurses' basic knowledge of the practice change fundamentals and provide opportunity for nursing staff to note individual observations regarding implementation of the new practice, and to make suggestions for improvement. Within four weeks of the initial implementation of the practice change, question items related to medication administration protocol will be added to patient exit surveys. The questions will have been reviewed and approved by hospital administrators and legal department staff. Patients will use a Liter 7-point scale to convey their level of satisfaction on the exit survey. The questions will be formulated to disclose patient confidence in the accuracy and timeliness of the administration of medication, and their understanding of the zero interruption protocol.

Steps to Maintain Change

Separately, staff will periodically conduct unannounced observations during medication preparation and medication administration rounds. These unannounced observations will be carried out on a peer-to-peer basis, as a support to nursing staff -- this process is likely to be well-received as most interruptions of nursing staff are not self-imposed, unless they are a reaction to an unexpected failure of the medication administration system. Even so, objectifying these observations -- in the manner of a continuous improvement approach -- ensures the focus is on the system as a hindrance or a support to patient care quality (Young and McClean, 2008). The role played by the committee for reducing medication administration errors is pivotal to maintenance of the practice change plan over time. The committee will regularly address issues related to fidelity of implementation, making recommendations for changes to strengthen the clinical practice change and to recognize the efforts of individual nurses to carry out the practice change plan. The committee will establish channels for communicating the progress and performance of teams and "floors" within the institution.


Clearly, interruptions during the administration of medication are a major challenge with the potential to have an adverse effect on stakeholders. To deal with these challenges, new procedures need to be created that focus on: using a comprehensive check list and instituting preventative steps that ensure readiness of the system, providing information to patients and family members about the hazard of interrupting nursing staff when they are conducting medication rounds, having others leave the room while medication is being administered and utilizing some type of signal (red) vest worn by nurses who are performing these tasks. These transformations will take place by training and informing stakeholders -- incorporating them into the process where it is feasible and appropriate, and providing regular education and training sessions. A survey will be conducted to analyze the procedures and determine if they are effective. This will offer insights about the success rates and how to address critical challenges. The procedures will provide opportunity for the early identification and remediation of key issues.

NR 451- Capstone Project Milestone #4: Design for Change Proposal



Bennett, J. (2006). Effects of interruptions to nurses during medication administration.

Nursing Management (Harrow), 16(9), 22-3.

PMID: 20222227 [PubMed - indexed for MEDLINE]

Biron, A., Lavoie-Tremblay, N., and Loiselle, C.G. (2009). Characteristics of work interruptions during medication administration. Journal of Nursing Scholarship, 41(4), 330-336. doi: 10.1111/j.1547-5069.20009.01300.x

Bottomley, M. (2010). Interruptions during drug rounds. Quality and Safety in Health Care. 9, 1-6. doi: 0.1136/qshc.2009.036871

Craig, J., Clanton, F., and Demeter, M. (2013). Reducing interruptions during medication administration: the White Vest study. To err is human: Building a safer health system. Institute of Medicine. Journal of Research in Nursing. doi: 10.1177/1744987113484737

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. doi:10.1001/archinternmed.2010.65.

Ferguson, M. (2005). Going blank: Factors contributing to interruptions to nurses. New England Journal of Medicine, 331, 69-73.

Franklin, B.D., O'Grady, K., Donyai, P., Jacklin, A., Barber, N. (2007). The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors, and staff-time: a before-and-after study. Quality and Safety in Health Care, 16(4), 279-284.

PMCID: PMC2464943

Hall, L.M., Ferguson-Pare M, Peter E, White, D., Besner J., Chisholm, A., Ferris, E., Fryers, M., Macleod, B. Pederson C. And Hemingway, A. (2010). Going blank: Factors contributing to interruptions to nurses. Journal of Nursing Management,18,1040-1047. doi: 10.1111/j.1365-2834.2010.01166

Hedburg and Larson (2004). Environmental elements affecting… [END OF PREVIEW] . . . READ MORE

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