Date of Graduation

Fall 12-12-2014

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Danijela Pavlic

Second Advisor

T. Gallo


The objective of this CNL Internship Project is to improve patient outcomes and nurse satisfaction by minimizing the avoidable interruptions that occur during medication administration. The microsystem is a pediatric and adult medical-surgical overflow unit at a large, urban teaching hospital in Northern California. A series of surveys for nurses and patients and observations of medication administrations were conducted to assess barriers during mediation administration. It was determined phone calls interrupt a nurse the most during medication administration. Interruptions leave the medication administration process vulnerable to errors because it disrupts the nurse’s workflow and thought process. Because most pediatric medication dosages are weight-based, nurses require another level of vigilance and accuracy. Hardmeier et al. (2014) states that because of weight-based dosing, lack of alternative drug formulations, or small drug volumes, three times as many adverse drug events are reported in the pediatric population due to medication administration errors. To address these interrupting phone calls, a Unit Clerk Phone Package with four tools was developed: an algorithm for triaging phone calls, a message sheet for taking non-emergent messages for nurses, a nurse med pass sign up sheet to indicate when a nurse was on a medication pass, and a script for the Unit Clerk to announce on the overhead speaker when medication administration has started and when it has ended. Prior to the intervention, 20% of phone calls during morning medication administration were not triaged and interrupted the nurse. After the implementation of the intervention, only 9% of phone calls during the morning medication administration time were not triaged correctly and interrupted the nurse.