Date of Graduation

Fall 12-12-2014

Document Type

Project/Capstone

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

First Advisor

Danijela Pavlic

Abstract

Background: Medication safety and preventing medication errors continues to be a high priority for hospitals and clinics, as medication errors are the most common and most costly errors in U.S. hospitals (Kliger, 2010, p. 690). Kliger (2010) reported that 450,000 medication errors occur annually, costing hospitals approximately $3.5 to 29 billion dollars a year. Furthermore, Ching, Long, Williams & Blackmore (2013) estimated that 770,000 injuries and deaths occur each year as a result of medication errors.

Purpose: To decrease medication errors by reducing the number of phone call and call light interruptions during the medication administration process.

Methods: Lippitt’s Change Theory was used to address the objective of decreasing medication errors by reducing the amount of phone call interruptions during the medication administration process. Initial audits were completed to observe the medication administration process on the medical-surgical/trauma unit. In addition, nurse surveys were conducted to further assess the opinion and perspective of the nurses working on the unit, and what they felt were the significant interruptions they faced while administering medications. Based on the initial audits and the nurse surveys, the aim of the project was focused on reducing phone call and call light interruptions by educating the unit clerk on how to triage incoming phone calls and call lights.

Therefore, in order to reduce the amount of phone call interruptions, a unit clerk packet was created with a unit clerk screening algorithm, overhead script, message sheet, and nurse sign-up sheet. In addition, pre-implementation and post-implementation data was collected on the number of pages and call lights, whether the page or call light was urgent, and whether the nurse was paged or called over the intercom system.

Results: The initial medication administration audits demonstrated that interruptions were significant during medication pass time. Furthermore, based on the nurse surveys and secondary audits of the medication administration process, it was found that phone calls were the most common interruption during medication pass time. Following the implementation of the unit clerk packet there was a 32% decrease in the amount of phone call and call light interruptions during the medication administration process.

Conclusion: Overall, with the implementation of the unit clerk packet and education of the unit clerk on how to triage phone calls and call lights, it may be concluded that this intervention can decrease the amount of interruptions during the medication administration process. However, medication errors continue to be a problem in U.S. hospitals, thus further research is necessary to investigate how to decrease errors and improve patient safety. It is suggested that further studies should be conducted, and recommendations from the literature should be taken into consideration.

Keywords: medication administration, medication errors, interruptions, unit clerk

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