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J Contin Educ Nurs. 2005 May-Jun;36(3):108-16; quiz 141-2.

Innovative approaches to reducing nurses' distractions during medication administration.

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Quality Coordinator, University Health System, San Antonio, Texas, USA.



Contributing factors to medication errors include distractions, lack of focus, and failure to follow standard operating procedures. The nursing unit is vulnerable to a multitude of interruptions and distractions that affect the working memory and the ability to focus during critical times. Methods that prevent these environmental effects on nurses can help avert medication errors.


A process improvement study examined the effects of standard protocols and visible signage within a hospital setting. The project was patterned after another study using similar techniques. Rapid Cycle Testing was used as one of the strategies for this process improvement project. Rapid Cycle Tests have become a part of the newly adopted Define, Measure, Analyze, Improve, and Control steps at this particular hospital.


As a result, a medication administration check-list improved focus and standardized practice. Visible signage also reduced nurses' distractions and improved focus.


The results provide evidence that protocol checklists and signage can be used as reminders to reduce distractions, and are simple, inexpensive tools for medication safety.

[Indexed for MEDLINE]

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