Preparing medications for distribution to a high volume of patients in a single pass is an important task that requires attention and precision. However, medication administration processes (MAPs) are frequently interrupted and these disruptions may create an opportunity for patient harm, according to study findings presented at the DNPs of Color 2022 Annual Conference held October 21 to 23, 2022, in Baltimore, MD.

The study was designed to examine the prevalence of MAP interruptions or distractions in the post-acute care setting and evaluate whether evidence-based practices may reduce these interruptions. To that end, the frequency of MAP interruptions and distractions in a 99-bed post-acute care center at West Coast University in Southern California was evaluated using a quasi-experimental design, explained study author Kim Rutley-Campbell, DNP, MSN.

During a total of 1480 minutes, MAP were interrupted 221 times during 154 medication administrations. Interruptions ranged from 17 to 52 times per shift and most occurred (76%) during the weekend. Overall, 69.6% of medication administrations were interrupted.

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The majority of interruptions were related to information sharing (58%) followed by patient needs (23%) and self-interruptions (14%). Most interruptions/distractions occurred during preparation (53%) or post-administration (38%) processes and few occurred during the administration process (9%).

A Call for Holistic Medication Safety Practices

Holistic medication safety practices may help to minimize interruptions during MAP, noted Dr Rutley-Campbell.

“Organizational leadership is critical to improving the quality of the medication administration processes, as medication safety will not evolve without a strong leadership emphasis on patient safety,” Dr Rutley-Campbell said.

One potential avenue for reducing these interruptions is to inform other members of staff that the nurse is beginning the MAP, Dr Rutley-Campbell explained. Also, medication administration policies should include protected medication administration time and interruption management strategies. Furthermore, all staff should receive yearly, multidisciplinary education about MAP and the potential effects interruptions or distractions may have on safe and accurate medication distribution.

This study was limited by the short data collection period (6 days) and by collecting data at only 1 site, making it unclear whether these findings are generalizable to other centers.

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Rutley-Campbell K. Medication administration processes: change the game and put some respect on it. Poster presented at: DNPs of Color 2022 Annual Conference; October 21-23, 2022; Baltimore, MD.