A Lean Approach to Improve Medication Administration Safety by Reducing Distractions and Interruptions

J Nurs Care Qual. 2020 Oct/Dec;35(4):E58-E62. doi: 10.1097/NCQ.0000000000000473.

Abstract

Background: Medication errors are potentially avoidable incidents that can lead to harm. Medications are often administered under challenging conditions, which creates opportunities for distractions and interruptions.

Purpose: The aim of this study was to reduce the number of interruptions and distractions experienced by nurses during the medication administration process.

Methods: A Lean approach was used to value stream map the process, devise solutions, and measure the impact of the change.

Results: Sources of distraction and interruption were identified. Through collaboration the medication administration process was standardized, and a purpose-built medication administration room was developed. Frequency of interruptions and distractions from all sources was reduced.

Conclusions: Value stream mapping the process enabled the identification of non-value-added activities that were threats to the integrity of the process. Standardizing the medication administration process and creating a safe space to facilitate the process successfully reduced interruptions and distractions from all sources.

MeSH terms

  • Attention
  • Drug Therapy / nursing*
  • Humans
  • Medication Errors / prevention & control*
  • Nursing Process
  • Patient Safety*
  • Safety Management*
  • Total Quality Management*