Medication Administration and the Complexity of Nursing Workflow

Medication administration is an increasingly complex process, influenced by the number of medications on the market, the number of medications prescribed for each patient, new medical technology and numerous administration policies and procedures. Adverse events initiated by medication error are a crucial area to improve patient safety. This project looked at the complexity of the medication administration process at a regional hospital and the effect of two medication distribution systems. A reduction in work complexity and time spent gathering medication and supplies, was a goal of this work; but more importantly was determining what barriers to safety and efficiency exist in the medication administration process and the impact of barcode scanning and other technologies. The concept of mobile medication units is attractive to both managers and clinicians; however it is only one solution to the problems with medication administration. Introduction and Background Medication administration is an increasingly complex process, influenced by the number of medications on the market, the number of medications prescribed for each patient, and the numerous policies and procedures created for their administration. Mayo and Duncan (2004) found that a “single [hospital] patient can receive up to 18 medications per day, and a nurse can administer as many as 50 medications per shift” (p. 209). While some researchers indicated that the solution is more nurse education or training (e.g. see Mayo & Duncan, 2004; and Tang, Sheu, Yu, Wei, & Chen, 2007), it does not appear that they have determined the feasibility of this solution and the increased time necessary to look up every unfamiliar medication. Most of the research which focuses on the causes of medication errors does not examine the processes involved in the administration of the medication. And yet, understanding the complexity in the nurses’ processes and workflow is necessary to develop safeguards and create more robust systems that reduce the probability of errors and adverse events. Current medication administration processes include many \ tasks, including but not limited to, assessing the patient to obtain pertinent data, gathering medications, confirming the five rights (right dose, patient, route, medication, and time), administering the medications, documenting administration, and observing for therapeutic and untoward effects. In studies of the delivery of nursing care in acute care settings, Potter et al. (2005) found that nurses spent 16% their time preparing or administering medication. In addition to the amount of time that the nurses spent in preparing and administering medication, Potter et al found that a significant number of interruptions occurred during this critical process. Interruptions impact the cognitive workload of the nurse, and create an environment where medication errors are more likely to occur. A second environmental factor that affects the nurses’ workflow, is the distance traveled to administer care during a shift. Welker, Decker, Adam, & Zone-Smith (2006) found that on average, ward nurses who were assigned three patients walked just over 4.1 miles per shift while a nurse assigned to six patients walked over 4.8 miles. As a large number of interruptions (22%) occurred within the medication rooms, which were highly visible and in high traffic locations (Potter et al., 2005), and while collecting supplies or traveling to and from patient rooms (Ebright, Patterson, Chalko, & Render, 2003), reducing the distances and frequency of repeated travel could have the ability to decrease the number of interruptions and possibly errors in medication administration. Adding new technology, revising policies and procedures, and providing more education have often been the approaches taken to reduce medication errors. Unfortunately these new technologies, such as computerized order entry and electronic medical records / charting, and new procedures, for instance bar code scanning both the medicine and the patient, can add complexity to the nurse’s taskload. The added complexity in correspondence with the additional time necessary to complete the additional steps can lead to workarounds and variations in care. Given the problems in the current medication administration processes, this work focused on facilitating the nurse’s role in the medication administration process. This study expands on the Braswell and Duggar (2006) investigation and compares processes at baseline and postintroduction of a new mobile medication system. To do this, the current medication administration and distribution process was fully documented to determine a baseline in workload complexity. Then a new mobile medication center was installed to allow nurses easier access to patient medications while traveling on the floor, and the medication administration and distribution process was remapped to demonstrate where process complexities were reduced and nurse workflow is more efficient. A similar study showed that the time nurses spend gathering medications and supplies can be dramatically reduced through this type of system (see Braswell & Duggar, 2006); however, they did not directly investigate the impact on the nursing process. Thus, this research is presented to document the impact of this technology on the nursing workflow at a regional hospital, and as an expansion on the work begun by Braswell and Duggar.