USING MEDICATION SAFETY ZONE TO REDUCE MEDICATION ERRORS

Francis Don L. Nero, MAN, RN1, Edna B. Dulay, MAN, RN1,

Roel M. Beljamin, MAN, RN2, Joseph Manuel Radam, MAN, RN2
1) University of Northern Philippines 2)Divine Word College of Bangued

ABSTRACT
Aim: In the Philippines, medication errors are rampant. Unfortunately, statistics regarding the

medication error incidence in the country is not an open book (Dumo, 2012). This evidence based

nursing project answered the Clinical question: Do staff nurses (P) who prepare medication in a

dedicated area (I) as compared to nurses who prepare medication at nurse’s station and patient’s bedside

(C) commit fewer medication errors (O)?

Methodology: Multiple literature databases were searched including Cochrane Database of

Systemic Reviews, National Guidelines Clearinghouse, Joanna Briggs Institute, MEDLINE, Cumulated

Index of Nursing and Allied Health Literature, Excerpta Medica Online, and Google Scholar using the

keywords medication error, medication preparation, nurse distraction, nurse interruption, medication

zone, medication preparation room, and safe preparation of medication. Four articles were retained and

graded with level four and six strength of evidence (Stetler) which included quasi-experimental study

and observational studies respectively. Institutions which utilize the practice and organizations that

promote and support the use of a medication safety zone were also identified. The Physical Environment

Guidelines for Medication Safety Zones from the United States Pharmacopeia was adapted. A synthesis

table of the review based on the Schultz format will be presented along with a recommended guideline

and plans for the collection of baseline data and outcome data.

Main Findings: The evidence showed that medication error is often related to nurse’s

interruption during drug preparation. This project proposes data measurement on medication errors
which will include the total medication doses for pre- and post-project periods, administration-related

medication error rates, and number of medication errors with harm.

Conclusion: A medication safety zone is recommended for the nurse’s to prepare medication to

reduce medication errors, increase the nurse’s confidence and the patient’s satisfaction. Implementation

of this guideline with its positive patient outcomes is dependent on the readiness for change within

institutions.
INTRODUCTION

The main professional goal of nurses is to provide and improve human health. Medication errors

are among the most common health threatening mistakes that affect patient care. Such mistakes are

considered as a global problem which increases mortality rates, length of hospital stay, and related costs

(Cheragi et. al., 2013)

Medication error is defined as "any preventable event that may cause or lead to inappropriate

medication use or patient harm while the medication is in the control of the health care professional,

patient, or consumer. Such events may be related to professional practice, health care products,

procedures, and systems, including prescribing; order communication; product labeling, packaging, and

nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

(National Coordinating Council for Medication Error Reporting and Prevention, 2013).

In the CNN Report (2000), the Institute of Medicine released a report showing that up to 98,000

patients die in hospitals every year due to medical errors. There have been reports in print media that

nursing mistakes alone are responsible for thousands of injuries and deaths.

Medication errors are a major problem in nursing. Since most cases of medication errors are not

reported by nurses, nursing managers must demonstrate positive responses to nurses who report

medication errors in order to improve patient safety (Cheragi et. al., 2013). However, Dumo (2012) in

her study cited that while medication errors are rampant in the Philippines, unfortunately, statistics

regarding the medication error incidence in the country is not an open book unlike to other countries. A

cross-sectional study on drug administration errors in 2010 conducted by medical students of Ateneo de

Manila University, Health Sciences Department stated that the Philippines has not yet strongly
implemented a reporting system for medication errors and the data remained undocumented and

overlooked.

Underreporting of medication administering errors (MAEs) is a threat to the quality of nursing

care. The reasons for MAEs are complex and vary by health professional and institution (Lin & Ma,

2009). The reporting barriers of fear, perception of nursing quality, and perception of nursing

professional development significantly contributed to failure to report (Chiang, Lin, Hsu, Ma, 2012).

Nurse executives continue to search for ways to support their staff nurses through enhancing

their work environment to promote professional practice environments (Lacey et. al., 2008). The Swiss

cheese model of system failure can be a guide to the health care professionals especially its

administrators to prevent or reduce errors that can occur during provision of health care. In this model,

every step in a process has the potential for failure, to varying degrees. The ideal system is analogous to

a stack of slices of Swiss cheese. Consider the holes to be opportunities for a process to fail, and each of

the slices as “defensive layers” in the

process. An error may allow a problem

to pass through a hole in one layer, but

in the next layer the holes are in

different places, and the problem should

be caught. Each layer is

a defense against potential error

impacting the outcome (Patient Safety-

Figure 1 Quality Improvement, 2005).

The Swiss Cheese Model when errors of holes are not aligned
 For a catastrophic error to occur, the holes need to align for each step in the process allowing all

defenses to be defeated and resulting

in an error. If the layers are set up with

all the holes lined up, this is an

inherently flawed system that will

allow a problem at the beginning to

progress all the way through to

adversely affect the outcome. Each

slice of cheese is an opportunity to

Figure 2 stop an error. The more defenses you

The Swiss Cheese Model when errors of holes are aligned

put up, the better. Also the fewer the holes and the smaller the holes, the more likely you are to

catch/stop errors that may occur (Patient Safety-Quality Improvement, 2005). Medication errors are like

the holes the t Swiss Cheese Model. The error may happen during the physician’s prescription of the

drug and order communication; during product labeling, packaging, dispensing in the pharmacy; and

during the nurses’ preparation and administration of the drug.

The Unites States Pharmacopeial Convention (2010) is promoting a dedicated area for

medication preparation called a medication safety zone. This area will give the nurses a place that will

be free from interruptions and distraction to prepare the medications. Many studies showed that there is

a link between the nurses’ interruption and distraction during drug preparation and the error they commit

on medications. The medication safety zone for drug preparation area is already being used in some

hospitals in the United States.

This evidence based practice study is significant to the following the nurse practitioners as this

provides guidelines in the safe preparation of medication, thereby could result to the reduction of
committing medication errors. Furthermore, the patients will also be benefited from this study as this

will advance their safety thereby enhance the quality of care being rendered to them during medication

administration.

METHODOLOGY

We searched the published literatures from the different electronic libraries to look into the

articles that would answer our clinical question in the PICO format, “Do medicating/medication nurses

(P) who prepare medication in a dedicated area (I) as compared to nurses who prepare medication at

nurse’s station and patient’s bedside (C) commit less medication errors (O)?”

Data Sources and Extraction

To look into evidence, we searched for articles that are relevant to our study from the

different electronic libraries. These electronic databases include the Cochrane Database of

Systemic Reviews, National Guidelines Clearinghouse, Joanna Briggs Institute, Medical

Literature Analysis and Retrieval System Online (MEDLINE), Cumulated Index of Nursing and

Allied Health Literature (CINAHL), Excerpta Medica Online (EMBASE), and the Google

Scholar. The key terms used in searching for evidence are medication error, medication

preparation, nurse’s distraction, nurse’s interruption, medication zone, medication preparation

room, and safe preparation of medication. Data that were extracted were evaluated through

individually critique method by the authors and through team consensus method.
Synthesis and Strength of Evidence

Evidence were gathered from articles that are searched and retrieved from different
electronic bases. Four articles were retained from hundreds of articles that were reviewed. Using
the Stetler (2001) strength of evidence to grade the articles, one article which was a quasi-
experimental study was graded as Level IV evidence and three observational studies were graded
as Level VI of evidence. These studies include the following studies:

Level Type of Study Articles

IV Quasi-experimental No Interruptions Please: Impact of a No Interruption Zone

Study on Medication Safety in Intensive Care Units

 Kyle Anthony, RN, BA, Clareen Wiencek, PhD,

CNP, ACHPN, Catherine Bauer, BSN, CCRN,
ACN, Barbara Daly, RN, PhD and Mary K.
Anthony, RN, PhD, CS (2010)
VI Observational Study Medication errors: perspectives of newly graduated and
experienced nurses

 Unver V, Tastan S, and Akbayrak N (2012)

VI Observational Study Impact of interruptions and distractions on dispensing

errors in an ambulatory care pharmacy

 Elizabeth Flynn, Kenneth Barker, Tyrone Gibson,

Robert Pearson, Bruce Berger and Leo Smith
(1999)
VI Observational Study Association of Interruptions With an Increased Risk and
Severity of Medication Administration Errors

 Johanna I. Westbrook, PhD, Amanda Woods, RN,

Med, Marilyn I. Rob, William T. M, Dunsmuir,
PhD and Richard O. Day, MD (2010)

The US Pharmacopeia Physical Environment Guidelines for Medication Safety Zone

The United States Pharmacopeial Convention (2010) released its physical environment

guidelines for medication safety zone. It defined the medication safety zone as a critical area

where medications are prescribed, orders are entered into a computer or transcribed onto paper

documents, and where medications are prepared, dispensed, or administered. In addition,

medication safety zones should be located in areas where the potential for distraction and

interruption is minimized. The standard for sound levels in medication safety zones is set at the

level of conversation. This is intended to ensure that critical verbal information can be heard

accurately. Furthermore, workers can be allowed to adjust features of the medication safety zone

to maximize their concentration and attention levels, and to optimize their performance. One

critically important medication safety zone for nurses is the medication preparation and

administration area, which should be analogous to the cockpit of an airplane.

Best Practices of Hospitals

Hospitals which practice the use of medication safety zone were identified. The

Children’s Hospital of Philadelphia (2013) reported that there were 42 percent fewer reduction in

medication related error when the use of medication safety zone was implemented. Also, the

New York City Health and Hospitals Corporation (2013) informed that there were 35%

medication related errors in their institution. Upon the implementation on the use of the

medication safety zone, they have noted that there was 100% reduction in the interruption rates.

Organizations/Agencies that Promote the Use of Dedicated Zones

Several organizations and agencies have stated their support on the use of medication

safety zone. The United States Pharmacopeia (2010) has proposed a physical environment

guideline which includes the utilization of a medication safety zone. The American College of

Obstetricians and Gynecologists (2012) has stated that strategies, such as no distraction zones, do

not disturb signs over medication preparation areas, and use of colored vests worn by health care

providers during the medication administration process are examples of methods for alerting

colleagues not to interrupt health care providers while they are focused on tasks related to the
 preparation or administration of medications. Also, the Institute for Safe Medication Practices

(2013) and the Medscape Multispecialty (2013) also specified their support on the guideline that

was proposed by the US Pharmacopeia.

RESULTS AND DISCUSSIONS

The evidence showed that medication error is often related to nurse’s interruption during drug

preparation. However, the use of medication safety zone in the hospitals can reduce medication related

errors committed by the nurses by making their medication preparation environment free from any

interruptions and distractions. Several hospitals are noted for their best practice in utilizing a dedicated

area for medication preparation. Different agencies and organizations have also showed their support in

the use and utilization of a medication safety zone.

The authors of this paper are planning to use the evidence gathered from the different electronic

data bases to propose the implementation of this evidence based project.

Identified Stakeholders

The authors have identified several stakeholders that might be of assistance in the

implementation of this project. Hospitals that might be the institution where this project could be

implemented are Gabriela Silang General Hospital, Abra Provincial Hospital, and Central Ilocos

Sur District Hospital. The authors also propose to seek the assistance of the University of

Northern Philippines and the Divine Word College of Bangued in the data gathering and analysis

after the implementation of this project to evaluate its effectiveness. The Local Government

Units of Ilocos Sur and Abra and the Association of Nursing Service Administrators of the
Philippines will also be considered for their assistance in the project’s implementation and

administration.

Potential Challenges

The authors identified challenged that may be present during the implementation of this

project. One challenge might be a weak political will wherein political will is defined as “the

exercise of an abstract feature of political authority to enforce certain act for the benefit of its

intention, usually for the public welfare”. Two, old practices of health care institutions might

also be a challenge in the project’s implementation. As per observation, many individuals can

hardly accept a change in the practice which they used to do. Third, the lack of knowledge of the

health care team members regarding the use of the medication zone as evidence based practice.

This practice will be new to them so they might be unaware of its implementation and process.

Fourth, the institutional policy will greatly affect the success of the project’s implementation. If

the institution of the policy would not allow the utilization of a medication safety zone, it will be

hard to implement the project.

Facilitators

To implement the project successfully, the authors identified facilitators to assist them in

its implementation. The Association of Nursing Service Administrators (ANSAP) will assist in

the policy and administrative functions of the health institutions to allow and monitor the

implementation of the project. The Hospital Committee on Infection Control will make sure that

patient safety and control of infection will be monitored closely while the project is being

implemented. The Research Committees and Quality Assurance Team will also look on the

proper execution of the project and its evaluation after it has been implemented.

Pilot Unit and EBP Changes

 The health institutions that were selected as the pilot unit for the implementation of the

project are the Gabriela Silang General Hospital, Ilocos Sur Central District Hospital, and the

Abra Provincial Hospital. Upon the implementation of the medication safety zone, the pilot unit

will expect some changes in their institutions. A separate or a designated area for medicine

preparation will be set-up and protocol on proper medicine preparation will be reviewed and

instilled.

Educational Plan and Definition of Outcomes

To ensure its proper implementation, educational plan must be considered to provide

information to the health care team especially the nurses about the process on the use of a

medication safety zone as evidence based practice. Seminars and trainings about the project and

prevention of medication related error will be made available. Policies and guidelines will also

be reviewed and formulated to align with the implementation of the project. To evaluate its

outcomes, the medication related error rates will be measured before and after the project

periods.

Data Collection, Entry and Analysis

Data will be collected to assess and evaluate the effectiveness of the project. A staff nurse

will be assigned as the data collector because she was known to the hospital staff. The data

collector will be trained by the primary investigator in event observation during medication

preparation and about the study protocol, which included the number of observation times, the

length of the observation period, and the events to be observed like occurrences, interruptions,

critical events, and unit activity. The data collector will be instructed to make notes of other

events or situations that occurred during the observation period. To observe all medication
 preparation areas, the data collector will be in a central location where all areas could

simultaneously be observed.

The Research Committee will also consider documentary analysis, observations, semi-

structured guided interview, questionnaire-checklist, and random sampling in the evaluation of

the effectiveness of the project. Mean, frequency and percentage, and Chi-square will be used on

the statistical analysis of the data.

CONCLUSION

A medication safety zone is recommended for the nurse’s to prepare medication to reduce

medication errors, increase the nurse’s confidence and the patient’s satisfaction. Implementation of this

guideline however will be directly proportional to the difficulties during the implementation process and

is dependent on the readiness for change within institutions.

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