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


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First Advisor

Danijela Pavlic

Second Advisor

T.J. Gallo


This Clinical Nurse Leader (CNL) project took place at a level I trauma center in the San Francisco Bay Area, on a 34-bed Medical Surgical, Behavioral Medicine and Acute Care for the Elderly (ACE) Specialty Unit. The goal was to improve the adverse events made during medication administration, which in turn reduces medical error costs and improves patient outcomes and patient safety. A review of the literature revealed several key points: (1) Medication errors are increasingly recognized as a significant, but preventable problem in our health care system, (2) Interruptions are implicated as a cause of clinical error, (3) Medication errors are associated with excess health care costs and most importantly, (4) Harm to the patient (Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). Project data was gathered from a variety of sources, including interviews with key stakeholders, unit observations and assessment, and staff and patient surveys. Interventions included informational posters, nurse and unit clerk education at staff meetings, identification of unit specific interruption patterns, face-to-face conversations, and distribution of educational packets. The pre-intervention survey of the day shift and night shift registered nurses (RN) (n=20) found that when asked how often a nurse was interrupted during each medication administration, 45% of the unit RNs reported they were “Usually (45-89%)” interrupted. In the same survey, 25% of the RNs reported “Always (90-100%)” being interrupted and 30% reported only being interrupted “Sometimes (1-44%)”. During a two-day pre-intervention observation of the unit clerk, 63 interruptions were observed during the medication administration time period of 8:00AM – 10:00AM. Of those 63 interruptions, 41 of those phone calls, pages and call lights were considered emergent, needing a nurse to be paged, while 22 of those interruptions were non-emergent. Although the post-intervention observation showed more phone call interruptions, the ratio of emergent calls and non-emergent calls showed that there was still a reduction of 6% in the interruptions to the nurses. The use of the triage algorithm for phone calls, pages and call lights aided in the reduction of disruptions. These results indicated that the interventions were successful, however there is a need to promote staff diligence and compliance for the use of the phone triage algorithm, message sheet, medication administration sign up sheet, and overhead announcement. A sustainability plan, including recommendations were presented to the unit nurse manager and the entire staff.

Included in

Nursing Commons