Other Titles
PechaKucha Presentation
Abstract
Problem Statement: Medication administration errors are a global healthcare issue that pose substantial risks, contributing significantly to patient safety events and mortality rates.1 This presentation reports on a student project conducted with oversight of a research mentor. The nursing student noted extreme deviations in witnessed clinical practice from learned practice.
Significance: The study purpose is to understand the correlation between the use of shortcuts during medication retrieval from electronic medication management systems (EMMS) and the incidence of medication errors. Specifically, it investigates how deviating from accepted nursing practice may contribute to errors such as medication confusion, omissions, misplacements, and/or dosage errors.2 Despite guidelines from The Joint Commission emphasizing patient safety and effective medication management, the practice of multitasking in medication management persists.3-5 This study aims to better understand normalized deviations from recommended practices and their implications for nursing care as well as nursing education.
Methods: An observational study will be conducted in the medication rooms on medical-surgical/telemetry units of two hospitals. Nurses will be observed as they retrieve medications from EMMS and will document any deviations from established best practices, specifically noting the type and frequency of each shortcut taken per trip to the EMMS. At the end of each observed shift, records will be reviewed to identify any medication errors that occurred during that period. Surveys will also be administered to nurses, seeking to understand their perspectives on shortcuts taken during medication administration and whether they have experienced errors as a result. Data collected from observations and surveys will be analyzed to explore patterns in medication administration practices and their potential link to medication errors, providing insights into opportunities for improved patient safety.
Results: An IRB application in process with study completion and data to be completed in time for this presentation. By identifying patterns and potential causes of medication errors, this study seeks to inform strategies for improving medication safety protocols and reinforcing adherence to established guidelines in nursing practice.
Discussion: Discussion will lean towards implications to improving medication administration, guidance for nurse educators, and integrity for practicing nurses.
Notes
References:
1. Arkin, L., Schuermann, A. A., Loerzel, V., & Penoyer, D. (2023). Original research: Exploring medication safety practices from the nurse’s perspective. AJN, American Journal of Nursing, 123(12), 18–28. https://doi.org/10.1097/01.naj.0000996552.02491.7d
2. Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010
3. The Joint Commission. (2024). Medication Management. 2024 Comprehensive Accreditation Manuals. MM.01.01.01–MM.09.01.01. https://www.jointcommission.org/standards/.
4. Simas, D. (2022). Evaluation of causes, contributing factors, and potential solutions to medication errors. Master’s Theses, Dissertations, Graduate Research and Major Papers Overview, 413. https://doi.org/10.28971/562022sd88
5. Wright, M. I., Polivka, B., Odom-Forren, J., & Christian, B. J. (2021). Normalization of Deviance: Concept Analysis. ANS. Advances in nursing science, 44(2), 171–180. https://doi.org/10.1097/ANS.0000000000000356
Sigma Membership
Non-member
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Observational
Research Approach
Other
Keywords:
Academic-clinical Partnership, Transition to Practice or Onboarding, Acute Care, Medication Errors, Clinical Practice Versus Learned Practice
Recommended Citation
Kennan, Samarah and Gary, Jodie, "Shortcuts in Obtaining Medication: Impact on Medication Errors in Nursing" (2025). International Nursing Research Congress (INRC). 205.
https://www.sigmarepository.org/inrc/2025/presentations_2025/205
Conference Name
36th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Seattle, Washington, 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.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Shortcuts in Obtaining Medication: Impact on Medication Errors in Nursing
Seattle, Washington, USA
Problem Statement: Medication administration errors are a global healthcare issue that pose substantial risks, contributing significantly to patient safety events and mortality rates.1 This presentation reports on a student project conducted with oversight of a research mentor. The nursing student noted extreme deviations in witnessed clinical practice from learned practice.
Significance: The study purpose is to understand the correlation between the use of shortcuts during medication retrieval from electronic medication management systems (EMMS) and the incidence of medication errors. Specifically, it investigates how deviating from accepted nursing practice may contribute to errors such as medication confusion, omissions, misplacements, and/or dosage errors.2 Despite guidelines from The Joint Commission emphasizing patient safety and effective medication management, the practice of multitasking in medication management persists.3-5 This study aims to better understand normalized deviations from recommended practices and their implications for nursing care as well as nursing education.
Methods: An observational study will be conducted in the medication rooms on medical-surgical/telemetry units of two hospitals. Nurses will be observed as they retrieve medications from EMMS and will document any deviations from established best practices, specifically noting the type and frequency of each shortcut taken per trip to the EMMS. At the end of each observed shift, records will be reviewed to identify any medication errors that occurred during that period. Surveys will also be administered to nurses, seeking to understand their perspectives on shortcuts taken during medication administration and whether they have experienced errors as a result. Data collected from observations and surveys will be analyzed to explore patterns in medication administration practices and their potential link to medication errors, providing insights into opportunities for improved patient safety.
Results: An IRB application in process with study completion and data to be completed in time for this presentation. By identifying patterns and potential causes of medication errors, this study seeks to inform strategies for improving medication safety protocols and reinforcing adherence to established guidelines in nursing practice.
Discussion: Discussion will lean towards implications to improving medication administration, guidance for nurse educators, and integrity for practicing nurses.
Description
This nursing student project explores shortcuts in medication retrieval from electronic systems. By observing nurses’ practices and surveying them about shortcut use and related errors, this research aims to uncover how deviations from best practices impact patient safety. Findings aim to highlight patterns in medication errors, offering insights to improve safety, and guidance for nursing education.