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  1. Elganzouri, Erika Sharpnack MSN, MBA, RN
  2. Standish, Cynthia A. MSN, RN-BC
  3. Androwich, Ida PhD, RN, NI-BC, FAAN


Objective: The aim of this study was to develop and test a method for assessing nursing effort and workflow in the medication administration process.


Background: Thousands of patients die each year from medication errors, and hospitals strive for error reduction. Bar-coding medication administration systems have been proposed as a solution; however, many hospitals lack the necessary preimplementation workflow process data on medication administration processes to evaluate the effectiveness of their current systems.


Method: A descriptive observation study of 151 nurses during 980 unique medication observations in medical-surgical units at a rural hospital, an urban community hospital, and an academic medical center was conducted.


Results: Nurses averaged more than 15 minutes on each medication pass and were at risk of an interruption or distraction with every medication pass.


Conclusion: System challenges faced by nurses during the medication administration process lead to threats to patient safety, work-arounds, workflow inefficiencies, and distractions during a time when focus is most needed to prevent error.