Paper writing INDIVIDUAL TOPIC SEARCH STRATEGY (ITSS) GUIDELINES PURPOSE The purpose of this initial paper is to briefly describe your search

Paper writing

INDIVIDUAL TOPIC SEARCH STRATEGY (ITSS) GUIDELINES

PURPOSE

The purpose of this initial paper is to briefly describe your search strategies when identifying two articles that pertain to an evidence-based practice topic of interest.

Course Outcomes

This assignment enables the student to meet the following course outcomes.

CO 1: Examine the sources of knowledge that contribute to professional nursing practice. (PO #7)
CO 2: Apply research principles to the interpretation of the content of published research studies. (POs #4 and #8)

DUE DATE

Week #2, Submit in ITSS in CANVAS

The colleges Late Assignment policy applies to this assignment.

POINTS POSSIBLE: 160 Points.

REQUIREMENTS/PREPARING THE PAPER

Each student will sign-up for a group to formulate an evidence-based practice topic of interest
Each group will formulate research question using PICO format.
Each group member will search, retrieve, and receive approval for
1 PRIMARY DATA ARTICLE
to answer the group Research Question.
Paper should include a Title and Reference pages.
Page Length: 3-4 pages Excluding Title and Reference pages
The paper will include the following:
Clinical Question
Describe problem
Significance of problem in terms of outcomes or statistics
Your PICOT question
Purpose of your paper
Level of Evidence
Type of question asked
Best evidence found to answer question
Search Strategy
Search terms
Databases used: Chamberlain Database
Refinement decisions made
Identification of most relevant article
Format
Correct grammar and spelling
Use of headings for each section
Use of APA format (7th edition)

Required to write the paper based on

PAPER FORMAT

1

Refers to Grading Rubric in page 3

Clinical Question

Research Question

Accurately and clearly states your research question using PICO format

Overview of the Problem

What statistics document this is a problem? (facts and figures)

Significance of the Problem

What health outcomes result from this problem. Why should people be concerned about this problem?

Purpose of Paper

Describe the purpose of topic search strategy (ITSS) paper

Search Strategy

Search Terms

List all terms used to search for your article (i.e. breast cancer, screening, mammography, intervention, assessment, influencing factors.etc.)

Library Databases

List Chamberlain library database used (i.e. EBSCO, Medline, OVID, PubMed….etc.)

Google search engine is NOT the library database

Availability of Articles

How many research articles were available to answer your research question?
Provide numbers of articles, NOT just saying plenty, sufficient, manyetc.

Refinement Decisions

What decision(s) have changed from your original search strategies? (i.e. peer-review, within last 5 years, primary data article, full-text.etc.)
What was your rationale for your decision to change from original search strategies?

Final Article

Describe decisions you made to specifically select 1 PRIMARY DATA ARTICLE as relevant for answering your Research Question

Level of Evidence

Addresses Topic/Relevance to PICO

Describe how article addresses the topic, purpose and key points

Evidence Level Pyramid

Identify and describe the level of evidence based on Evidence Level/Hierarchy Pyramid
Refers to Handout (Quick Guide to Designs in an Evidence Hierarchy)

Study Type

Identify study type of article: Quantitative, Qualitative, or Mixed-Method Study

Grading Rubric & Description for Individual Topic Search Strategy

Clinical Question (45)

Research Question

(PICO)

15

Accurately and clearly states your Research Question as formulated and stated in PICO format

Purpose of Paper

10

Describe the purpose of your ITSS paper

Overview of Problem

10

What statistics document this is a problem?

Significance of Problem

10

What health outcomes result from your problem?

Search Strategy (65)

Search Terms

10

List terms used to search for your articles (breast cancer, screening, mammography, intervention, factors..etc)

Library Databases

10

List Chamberlain library database you used (i.e. EBSCO, Medline, OVID, PubMed)

Google search engine is NOT the library database

Availability of Articles

5

How many research articles were available to answer your research question? Provide numbers

Refinement Decisions

10

As you did your search, what decisions did you make in refinement to get your required articles down to a reasonable number for review?

5

What was your rationale for your decision to change?

5

How many research articles were available to answer your research question after your refinement process?

Final Article

10

Describe decisions you made to specifically select
ONE PRIMARY DATA ARTICLE
as relevant for answering your Research Question

10

Submit a hard copy of selected article.

Level of Evidence (20)

Relevance to PICO

Evidence Level Pyramid

Study Type

10

Describe how the article addresses the topic (i.e. therapy, prognosis, risk factors, assessments, or meanings.etc)

5

Identify and describe the Level of Evidence based on level of evidence pyramid (see handout)

5

Identify the study type based on the study design: Quantitative, Qualitative, Descriptive, Mixed-Method Study

Format

5

Use of required Headings and Subheading for each category

10

APA Format (7th ed. ) references, citations

10

Correct grammar and spelling

5

Paper length (3-4 pages)

Total Points: /160 Points Cover

2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2016498

CE 1.0 hour

Fran Flynn, APRN, MS, BC-CNS
Julie Q. Evanish, RN, BS, PCCN
Josephine M. Fernald, RN, BSN, PCCN
Dawn E. Hutchinson, RN, BSN, PCCN
Cheryl Lefaiver, RN, PhD, CCRP

Progressive Care Nurses
Improving Patient Safety by
Limiting Interruptions During
Medication Administration

BACKGROUND Because of the high frequency of interruptions during medication administration, the
effectiveness of strategies to limit interruptions during medication administration has been evaluated in
numerous quality improvement initiatives in an effort to reduce medication administration errors.
OBJECTIVES To evaluate the effectiveness of evidence-based strategies to limit interruptions during
scheduled, peak medication administration times in 3 progressive cardiac care units (PCCUs). A sec-
ondary aim of the project was to evaluate the impact of limiting interruptions on medication errors.
METHODS The percentages of interruptions and medication errors before and after implementation of
evidence-based strategies to limit interruptions were measured by using direct observations of nurses
on 2 PCCUs. Nurses in a third PCCU served as a comparison group.
RESULTS Interruptions (P < .001) and medication errors (P = .02) decreased significantly in 1 PCCU after implementation of evidence-based strategies to limit interruptions. Avoidable interruptions decreased 83% in PCCU1 and 53% in PCCU2 after implementation of the evidence-based strategies. CONCLUSIONS Implementation of evidence-based strategies to limit interruptions in PCCUs decreases avoidable interruptions and promotes patient safety. (Critical Care Nurse. 2016;36[4]:19-35) This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives: 1. Describe similarities between the principles of the sterile cockpit concept used in the aviation industry and the Nurses Uninterrupted Passing Medications Safely (NUPASS) guidelines to promote safety 2. Discuss the current evidence supporting use of interruption limiting strategies to reduce medication administration errors in the acute care setting 3. Implement evidence-based strategies to limit interruptions during medication administration To complete evaluation for CE contact hour(s) for test #C1642, visit www.ccnonline.org and click the CE Articles button. No CE test fee for AACN members. This test expires on August 1, 2019. The American Association of Critical-Care Nurses is an accredited provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Registered Nursing of California (#01036) and Louisiana (#LSBN12). N urses play a critical role in promoting patient safety through surveillance and inter- ception of errors that cause patient harm as hospitals and health care systems strive to become high-reliability organizations.1 The Institute of Medicine estimates that medication errors result in several thousand deaths annually.2 Interruptions during complex or high-risk activities such as medication administration increase risk of www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 19 20 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org Authors Fran Flynn was the advanced practice nurse on one of the progressive cardiac units at the time of the project and is now the advanced practice nurse for the inpatient palliative care service, Advocate Christ Medical Center, Oak Lawn, Illinois. Julie Q. Evanish was a bedside nurse in one of the progressive cardiac units at the time of the project and is now working in the outpatient pain clinic, Advocate Christ Medical Center. Josephine M. Fernald was a bedside nurse in one of the progressive cardiac care units at the time of the project and is now working in the outpatient heart failure clinic, Advocate Christ Medical Center. Dawn E. Hutchinson was a bedside nurse in a progressive cardiac care unit when the study was done and is now a clinical informatics specialist, Advocate Christ Medical Center. Cheryl Lefaiver was the professional nurse researcher for the medical center when the study was done and is now manager of patient-centered outcomes research for Advocate Center for Pediatric Research, Advocate Christ Medical Center. Corresponding author: Fran Flynn, APRN, MS, BC-CNS, Advocate Christ Medical Center, 4400 W 95th St, Oak Lawn, IL 60453 (e-mail: [emailprotected]). To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [emailprotected] patient harm, and strategies to reduce interruptions and manage them appropriately are needed.3 On the basis of the current evidence, the Institute of Medicine recommends that organizations adopt strategies to reduce interruptions during medication administration as part of a comprehensive medication safety program.2 The quality improvement project described here evaluates the impact of adopting evidence-based strate- gies to limit interruptions during medication adminis- tration in 2 progressive cardiac care units (PCCUs) at Advocate Christ Medical Center, a Magnet-designated tertiary care center in the Midwest. A third PCCU served as a comparison unit and, therefore, did not adopt the interruption-limiting strategies. A secondary aim of the project was to evaluate how limiting interruptions affected medication errors in this setting. Background In a plenary speech at the 2008 National Teaching Institute, the former president of the American Associa- tion of Critical-Care Nurses challenged more than 9000

nurses in attendance to avoid multitasking and interrup-

tions when

administering

medications

in order to

prevent medi-

cation errors.

Attendance at this speech was the inspiration for this

project and became the springboard for addressing

existing nursing concerns about interruptions.

Review of the Literature
Observational studies describe the high cognitive

work of nurses coupled with frequent interruptions and

multitasking behaviors during direct patient care activ-

ities in acute care settings.4-8 The work environment is

error-prone, especially during complex or high-risk

activities, because interruptions and multitasking

behaviors create conditions affecting working memory

and attention resources.9,10 Nurses cognitive processes

during medication administration are complex and

require a high degree of critical thinking and vigilance

to prevent patient harm.11 Medication administration

is one of the most frequently interrupted nursing

activities,4,6,12 and strategies to limit interruptions are

recommended to improve patient safety.

Studies describing the frequency and characteristics

of interruptions during medication administration show

that nurses have little protected time to focus on medica-

tion administration because of short, frequent interrup-

tions.6-9,12,13 The most common source of interruptions is

interactions with other nursing staff seeking information

or assistance with patient care.13 The frequency of inter-

ruptions by other care providers varied significantly

across studies.13,14 Although they were not the most fre-

quent source of interruptions, phone calls were identi-

fied by nurses as one of the most disruptive sources of

interruptions and one of the most likely sources of inter-

ruptions to be associated with medication errors.8,12

System failures such as missing medications and access

to equipment and supplies were also identified as sources

of interruptions that are potentially avoidable.7,8,12-16

Other avoidable interruptions cited in the literature are

the tendency of nurses to interrupt each other with

conversations unrelated to medication administration7,17-19

while preparing medications and to respond immedi-

ately to requests from others when interrupted.7,15,20

These findings support the idea that interruptions are

an accepted part of nursing practice and suggest the

Attendance at the National Teaching
Institute was the inspiration for this
project and the springboard for
addressing existing nursing concerns
about interruptions.

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 21

need for culture change to limit avoidable interruptions,

especially during complex or high-risk activities such as

medication administration.

Development and testing of strategies to limit inter-

ruptions during the medication administration process

are primarily based on research from the aviation indus-

try. In 1981, the Federal Aviation Authority mandated

use of standard operating procedures to create a sterile

cockpit situation aimed at reducing unsafe working con-

ditions and preventing errors during high-risk activities

such as aircraft takeoff and landing. Essential aspects of

the sterile cockpit concept include eliminating interrup-

tions, prohibiting communication unrelated to critical

tasks, and maximizing teamwork and coordination

during high-risk activities.21,22 The majority of published

clinical initiatives to limit interruptions during medica-

tion administration are nurse-led quality improvement

projects involving implementation of a set of strategies

to limit interruptions (Table 1). The goal of these initia-

tives is to provide nurses with time to remain focused

and undisturbed while preparing and administering

medications. Direct observations of nurses preparing

and administering medications during peak, scheduled

administration times were used to study interruptions

in these quality improvement projects. Results of these

projects demonstrate that implementation of a set of

strategies is effective in limiting interruptions and may

improve patient safety by decreasing medication errors.

To date, 1 study3 examining the direct relationship

between work interruptions and hospital medication

administration errors has been published. Results of this

landmark study demonstrated that the frequency of

interruptions during medication administration increased

the risk of both the number and severity of medication

errors. Table 2 provides a detailed analysis of the litera-

ture regarding cognitive work of nurses and the com-

plexity of the work environment, interruptions during

medication administration, strategies used to limit inter-

ruptions during medication administration, and the

contribution of interruptions to medication errors.

Introduction to the Progressive Cardiac
Care Quality Improvement Project

The PCCU quality improvement project was developed

and implemented on the basis of the work of Nguyen

and colleagues.25 In the quality improvement project

presented here, the project team implemented a set of

evidence-based strategies to limit interruptions during

scheduled, peak medication administration times in

the progressive cardiac care setting. The project team

embedded the interruption strategies into practice guide-

lines to promote communication, coordination of care,

and teamwork during medication administration. The

guidelines are referred to as the NUPASS guidelines, on

the basis of the projects name: Nurses Uninterrupted

Passing Medications Safely (Table 3).

The projects conceptual framework is based on the

medical centers Evidence-Based Practice (EBP) Model

(Figure 1). The EBP model was adopted and modified

on the basis of the Iowa model.30 Using the EBP model

as a guide, the project team initiated a pilot practice

change based on the current evidence supporting use

of strategies to limit interruptions during medication

administration. The pilot practice change was designed

to answer 2 questions: (1) Does implementation of the

NUPASS guidelines decrease interruptions during medi-

cation administration? and (2) Do medication errors

decrease following implementation of NUPASS guide-

lines? The pilot practice change was conducted on 2 of

the 3 PCCUs; PCCU1 and PCCU2 were the intervention

units that implemented the NUPASS guidelines, and

PCCU3 served as a comparison unit.

Patients cared for in the high-acuity PCCUs typically

included patients who required invasive diagnostic and

interventional cardiovascular procedures, cardiovascular

surgery, and arrhythmia management. Common medi-

cal diagnoses included acute coronary syndrome, heart

Table 1 Evidence-based strategies to limit
interruptions during medication administration

1. Hourly patient rounds23

2. Scripts for triage of phone calls17,22,24-26

3. Protected time for passing medications without
interruptions17,22,25

4. Signage to remind staff to limit interruptions12,17,22,24-26

5. No interruption zone/quiet zone established in
medication rooms17,24-27

6. Phone calls to nurses limited during medication
administration17,25

7. Nurses don visible wear as a nonverbal cue that they
are administering medications and are not to be
disturbed12,17,22,26

8. Distribution of patient/family education materials about
limiting interruptions during medication administration12,17

22 CriticalCareNurse Vol 36, No. 4, AUGUST 2016 www.ccnonline.org22 C i i lC N

Table 2 Detailed review of the literature

Reference

Potter et al,4 2005

Eisenhower et al,11 2007

Kalisch and Aebersold,5
2010

Cornell and Riordan,9
2011

Kreckler et al,6 2008

Biron et al,7 2009

Palese et al,8 2009

Biron et al,13 2009

Sample/setting

Convenience sample of 7 nurses with
acute care experience and clinical
background

Large, tertiary medical center in the
Midwest

Convenience sample of 40 nurses
working in intermediate medical-
surgical intensive care unit
(M/S ICU) and ante/postpartum unit

Large, tertiary teaching hospital in
the Northeast

Convenience sample of 36 nurses
from 5 M/S units, 1 ICU, and 1
progressive care unit

Seven patient care units in 2
Midwestern hospitals including
an academic medical center and a
community-based teaching hospital

Convenience sample of 19 nurses
from 2 hospitals including 8 nurses
on an M/S unit at a suburban,
acute care hospital and 11 nurses
on a pediatric oncology unit at a
pediatric research hospital in the
United States

Convenience sample of nurses
working on a 37-bed surgical unit
at a teaching hospital in the United
Kingdom

Convenience sample of 18 nurses
working on a medical unit at a
tertiary care teaching hospital in
Quebec

A convenience sample of nurses
working on 7 surgical units across
multiple, similar type hospitals in
Northern Italy

Articles from 1980 to 2008 were
analyzed

Design/procedures

Mixed method ethnographic observa-
tional study combining quantitative
human factor engineering techniques
with summative nurse interviews

Nurses were observed for a total of 48 h

Descriptive study with semistructured
interviews

Observational study
A previously validated instrument

referred to as the Communication
Observation Tool was used by 4
trained staff nurses to collect data

For the purpose of this study, both
procedural failures and medication
administration errors were counted
as errors

Observational study limited to nurs-
ing activities outside of the patients
room during 85.2 h of observation

Observational study
Thirty-eight medication passes were

observed in 5 weeks

Observational study
Descriptive data included source and

duration of interruptions, nursing
tasks and location during interrup-
tions and strategies used by nurses
to manage interruptions

Mixed-method study combining
observation of nurses during medica-
tion administration followed by nurse
interviews during a 3-month period

Systematic review
Fourteen of 23 studies selected for

analysis reported observation times
and interruption frequencies and
therefore, underwent further analysis

Purpose

Analyze nurses cognitive work
and how environmental fac-
tors create disruptions that
pose risk for medical errors

Describe nurses thinking
during medication admin-
istration before and after
implementation of bar-code
medication scanning (point-
of-care technology)

Evaluate the type and extent
of work interruptions, multi-
tasking, and errors

Assess the complexity of
nurse workflow and review
its cognitive implications

Determine the time required
by nurses to deal with inter-
ruptions and the nature of
nurses work interruptions
(WIs) during medication
administration

Document characteristics of
nurses WIs during medi-
cation administration

Examine the frequency and
perceived risk of WIs during
medication administration

Review the evidence on
nurses interruption rates,
characteristics of WIs, and
contribution of WIs to medi-
cation administration errors

A. Cognitive work of nurses and complex work environment

B. Interruptions during medication administration

www.ccnonline.org CriticalCareNurse Vol 36, No. 4, AUGUST 2016 23C i i lC N 23

Findings/conclusions

Nurses averaged 9 cognitive shifts per hour or a shift in attention focus once every 6-7 min
The human factor engineer found 5.9 interruptions per hour and the nurse researcher found an average of 3.4 interruptions per hour
Twenty-two percent of interruptions occurred in the medication room during medication preparation, and no attempt was made by

nurses to control sources of the interruptions

Nurses constant vigilance to provide the appropriate medication was a common theme found in the content analysis
Nurses thinking was categorized into 10 descriptive categories; the only change in thinking after implementing bar-code scanning was

the descriptive category related to checking medications
Key aspects of critical thinking identified included assessment of the patient before and after administration of medications, interpretation

and verification of relevant laboratory data, application of knowledge to specific patient situations, anticipatory problem solving related
to the patients expected clinical trajectory and consultation with health care team members to prevent medication errors and adverse
drug events

The mean interruption rate observed at the 2 hospitals was 10 interruptions per hour resulting in a break in task more than 1/3 of the time
Interruptions occurred every 6 minutes for hospital 1 and every 4.5 min for hospital 2; nurses were interrupted during medication

administration 57% and 36% of the time in hospital 1 and hospital 2, respectively
Nurses engaged in multitasking an average of 30% and 40% of the time in hospital 1 and hospital 2, respectively
Significantly more interruptions (P < .001), multitasking (P < .001), and breaks in task (P < .001) occurred in ICUs than in the M/S units No more errors were found when nurses were interrupted or multitasking vs when nurses were not interrupted or multitasking More than 2000 tasks were recorded on each unit during 35.7 h of observation on the M/S unit and 49.5 h of observation on the pediatric oncology unit The duration of tasks was short with a mean of 62.4 (SD, 127.7) s and 49.5 (SD, 81.6) s on the M/S unit and pediatric oncology unit, respectively The reason for switching tasks (self-directed or external) was not discernible Nurses frequently changed locations when switching tasks Medication passes were interrupted a mean of 11% of the time Two-thirds of the medication passes were interrupted with a mean of 2.61 interruptions per medication pass The 3 most frequent sources of interruptions in descending order were (1) interruptions by the nurse administering medication (self-initiated), (2) interruptions by physicians, and (3) interruptions by other staff and patients Phone calls were not the most frequent source of interruption; however, they were found to be significant because of their longer duration WIs averaged 6.3 per hour (5.2 per hour during medication preparation and 6.8 per hour during medication administration) WIs were of short duration with a mean of 1 min 32 sec (SD, 2 min) The most frequent WIs during medication preparation were by nurse colleagues followed by system failures due to missing medication and equipment Nurses preparing medications were interrupted by other nurses for personal matters 36% of the time and to exchange verbal reports 22% of the time The most frequent WIs during medication administration were self-initiated and by patients during direct patient care activities Nurses handled WIs immediately more than 98% of the time; the proportion of WIs handled immediately was similar during both medication preparation and administration (98.8% and 97.6%, respectively) A mean of 1 interruption per 3.2 drugs administered occurred during medication administration When there was an increased number of drugs per medication pass for a single patient, the number of interruptions increased significantly (P = .05). Nurses intervened immediately when interrupted 96% of the time Nurses perceived interruptions related to management of phone calls to be the highest risk for error during medication administration Pooled data from 14 studies found WIs occurred at a rate of 6.7 interruptions per hour The majority of interruptions were self-initiated by nurses administering medications during face-to-face interactions, occurred most frequently during direct patient care, and were of short duration ranging from 45 sec to 1.2 min Only 1 nonexperimental study documented the contribution of interruptions to medication errors with evidence of a significant association (P = .01). Continued Table 2 Continued Reference Pape,22 2003 Nguyen et al,5 2009 Anthony et al,27 2010 Freeman et al,17 2013 Williams et al,26 2014 Sample/setting Convenience sample of M/S unit nurses were observed during a single medication pass for assigned patients in a 520-bed acute care hospital in Texas Forty-five nurses working on a 25-bed M/S unit at an academic teaching hospital in Northern California The project was conducted in partnership with a larger quality improvement (QI) initiative spon- sored by the Integrated Nurse Leadership Program aimed at improving patient safety and involved 7 hospitals in the San Francisco Bay28 Convenience sample of medical ICU and surgical ICU nurses working in a tertiary academic medical center in Cleveland, Ohio Convenience sample of 99 nurses in a cardiac and thoracic surgical step-down unit at a large, academic medical center in the Midwest Convenience sample of nurses working in a surgical progressive care unit (52 before intervention and 48 after intervention) Academic medical center in the southeastern United States Design/procedures Quasi-experimental 3-group study design including a comparison group and 2 intervention groups A validated instrument referred to as the Medication Administration Distraction Observation Sheet (MADOS) was used to count distractions A longitudinal observational QI project One hundred medication passes were observed before the interven- tion and at 6 months and 1 year after the intervention Observational pilot project A no interruption zone (NIZ) was created by placing red tape around all medication preparation areas to signify that nurses were not to be disturbed while preparing medications The number of interruptions before and 4 weeks after the NIZ was implemented were measured Nurses observed were blinded to the purpose of the study Observational QI project. A modified version of the MADOS instrument was used to count the number and type of interruptions Observational study Distractions and interruptions were measured using the MADOS instru- ment before and 2 months after implementation of 5 evidence- based safety strategies including nursing staff education, use of a medication safety vest, NIZ in medication preparation areas, signage on the unit and patient rooms, and a resource tool for scripting responses to interruptions Purpose Test the effectiveness of 2 interventions (focused protocol and medsafe protocol) to reduce distrac- tions during medication administration in comparison to usual practice Determine which distractors are more predictive of nurses being distracted during medication administration Evaluate whether a safety initiative referred to as the Med Pass Time Out was effective and sustainable in reducing medication administration errors Evaluate the effect of a NIZ on the number of interruptions during medication preparation Determine whether implemen- tation of a set of interventions would reduce interruptions during medication adminis- tration A secondary project goal was to reduce medication errors Interventions implemented were previously described in the literature, including wearing a lighted lanyard during medication adminis- tration, triage of phone calls, creating an NIZ in the medication preparation area, signage, and staff and patient/family education To evaluate the effectiveness of implementing 5 evidence- based safety strategies to reduce distractions and interruptions during medication preparation C. Strategies to limit interruptions Findings/conclusions Significant differences in the mean number of distractions were found between the comparison group and both intervention groups (P < .001) as well as between the 2 intervention groups (focused protocol [P = .01] and medsafe protocol [P < .001]) The significant difference between the 2 intervention groups was attributed to use of a visible symbol that the nurse wore during medication administration (a red vest with the lettering Medsafe Nurse, Do Not Disturb) Conversation accounted for the majority (93%) of the variance in distractions, followed by interruptions by personnel (90%) and loud noises Uninterrupted time increased from 81% to 99% of the time at 6 months and 1 year after implementation of the Med Pass Time Out Medication errors decreased from 2% to 1% at 6 months and improvement was sustained at 1 year No statistical analysis The number of interruptions decreased by 40.9% (from 31.8% to 18.8%) after implementation of the NIZ (P = .03). The proportion of interruptions initiated by nurses preparing medications (self-initiated interruptions) decreased from 25% to 0% following implementation of the NIZ Mean number of interruptions decreased from 3.29 to 1.18 during medication administration Medication errors decreased by 28 events when compared with the same time period the year before Patients, nurses, and patients family members represented the top 3 sources of interruptions before implementing interventions to reduce interruptions; 1 month