Abstract
Medication errors are a significant global challenge in hospitals, occurring at various stages of the medication management process. Wrong-time medication administration errors (WTMAE)—defined as administering medication beyond prescribed time—are most frequent during medication administration phase. It poses major risks to overall healthcare outcomes.
This project aimed to reduce WTMAEs and improve adherence to on-time medication administration with "No Interruption Sign" (NIS) in a medical-surgical unit.
It was a cross-sectional study. It was conducted for 8 weeks from February 19 through April 14, 2024, in an Academic Hospital in New York focusing on the 10 am medication administration process. Initially, the rate of WTMAEs at 10 am routine medication administration in the selected unit was 38.09%. After eight weeks of using the NIS, WTMAEs decreased to 22.14%, representing a 16% improvement. The use of NIS and increased staff awareness helped reduce WTMAEs. Data was collected from electronic medical records (EMAR).
Pre-and-post-implementation data was collected as late doses of medication as normal level variables (late = 1 or not late = 0). Pearson’s Chi-square test was used to assess the clinical significance. Pearson’s chi-square was deemed statistically significant if the p-value was < .05. In the pre-implementation phase, 3194 doses (38%) were late out of the 8385 scheduled doses. After implementation of NIS, WTMAEs went down to 1511 (22%) out of 6825 scheduled doses. Pearson’s chi-square exhibited a statistically significant variation between the frequencies of late medications in the current practice and the post-implementation phase, (1, N = 15210) = 448.17, p = < .001.
After initiating the quality improvement project, a clinically significant 16% decrease in the frequency of late medications was observed. The project demonstrated a significant decrease, with 1683 fewer patients having late medication administered compared to the current practices.
The introduction of the NIS notably reduced disruptions during medication administration, helping to improve workflow and a 16% reduction in WTMAEs. This improvement in adherence to on-time medication administration benefits patient outcomes and enhances nurse satisfaction by allowing them to focus on their tasks with fewer distractions. Reduced interruptions can lower stress levels and decrease the risk of burnout, ultimately fostering a safer and more efficient healthcare environment.
Notes
References included on last pages of slide deck.
Sigma Membership
Non-member
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Quality Improvement
Research Approach
Translational Research/Evidence-based Practice
Keywords:
Instrument and Tool Development, Medication Administration, Medication Error Reduction, Interruption Mitigation
Recommended Citation
Roy, Anjana, "Preventing Interruptions Improve Adherence to On-Time Medication Administration" (2025). Biennial Convention (CONV). 52.
https://www.sigmarepository.org/convention/2025/presentations_2025/52
Conference Name
48th Biennial Convention
Conference Host
Sigma Theta Tau International
Conference Location
Indianapolis, Indiana, USA
Conference Year
2025
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2025-11-19
Preventing Interruptions Improve Adherence to On-Time Medication Administration
Indianapolis, Indiana, USA
Medication errors are a significant global challenge in hospitals, occurring at various stages of the medication management process. Wrong-time medication administration errors (WTMAE)—defined as administering medication beyond prescribed time—are most frequent during medication administration phase. It poses major risks to overall healthcare outcomes.
This project aimed to reduce WTMAEs and improve adherence to on-time medication administration with "No Interruption Sign" (NIS) in a medical-surgical unit.
It was a cross-sectional study. It was conducted for 8 weeks from February 19 through April 14, 2024, in an Academic Hospital in New York focusing on the 10 am medication administration process. Initially, the rate of WTMAEs at 10 am routine medication administration in the selected unit was 38.09%. After eight weeks of using the NIS, WTMAEs decreased to 22.14%, representing a 16% improvement. The use of NIS and increased staff awareness helped reduce WTMAEs. Data was collected from electronic medical records (EMAR).
Pre-and-post-implementation data was collected as late doses of medication as normal level variables (late = 1 or not late = 0). Pearson’s Chi-square test was used to assess the clinical significance. Pearson’s chi-square was deemed statistically significant if the p-value was < .05. In the pre-implementation phase, 3194 doses (38%) were late out of the 8385 scheduled doses. After implementation of NIS, WTMAEs went down to 1511 (22%) out of 6825 scheduled doses. Pearson’s chi-square exhibited a statistically significant variation between the frequencies of late medications in the current practice and the post-implementation phase, (1, N = 15210) = 448.17, p = < .001.
After initiating the quality improvement project, a clinically significant 16% decrease in the frequency of late medications was observed. The project demonstrated a significant decrease, with 1683 fewer patients having late medication administered compared to the current practices.
The introduction of the NIS notably reduced disruptions during medication administration, helping to improve workflow and a 16% reduction in WTMAEs. This improvement in adherence to on-time medication administration benefits patient outcomes and enhances nurse satisfaction by allowing them to focus on their tasks with fewer distractions. Reduced interruptions can lower stress levels and decrease the risk of burnout, ultimately fostering a safer and more efficient healthcare environment.
Description
Frequent interruptions during medication administration impose major challenges to healthcare, resulting in adverse outcomes. Preventing interruptions helps improve on-time medication administration and healthcare outcomes. A simple strategy like a NIS and improving staff awareness can help mitigate the impact of interruptions. A combination of strategy, policy support, and adequate resources would empower caregivers to deliver medications on time, ensuring better care for patients.