Date of Award

Summer 2022

Project Type


College or School




Degree Name

Master of Science

First Advisor

Pamela Kallmerten


Background: Patient safety is a top priority for registered nurses (RNs) while caring for individuals in the healthcare setting. Of the various responsibilities of an inpatient RN, administering injectable medications pose significant risks to patients if done incorrectly. Given these known risks, the RNs of an inpatient medical-surgical microsystem were studied during the process of preparing these medications.

Local Problem: Through observations (N = 20), it was noticed that 13 (65%) of the preparations were done at a location referred to as the nurse server counter. This is problematic since this location does not provide the RN with access to the electronic medication administration record (eMAR), meaning that these preparations were done without verifying the Seven Rights of Medication Administration. These findings generated this quality improvement (QI) project and the specific aim to decrease the percentage of RNs that prepare injectable medications at this location from 65% to 50% by July 29, 2022.

Methods: A pre-implementation survey, assessing the RNs’ knowledge of safe medication practices and how often they access the eMAR during medication preparation was distributed. This survey facilitated in outlining the intervention, including the plan to gather an additional 20 observations. The Plan-Do-Study-Act model of improvement was selected as the framework for this project. Descriptive statistical analysis was used to analyze the results.

Intervention: The intervention began with an informed consent process, which allowed RNs to agree to participate. Educational meetings were held with the participants which reviewed topics relating to the importance of safe medication practices. Then, visual reminders were put on display throughout the microsystem which were meant to redirect RNs to prepare medications with the eMAR open. The RNs were then observed as they prepared injectable medications. Finally, the participants were asked to complete a survey which assessed the effectiveness of the intervention.

Results: Six RNs provided consent to participate in the intervention. The project was terminated after collecting only 10 observations given this cycle’s deadline of July 29, 2022. Of the 10 observations of preparing injectable medications (N = 10), one (10%) was done at the nurse server counter. Additionally, five of the six RNs completed the post-implementation survey. The responses indicate that the educational meetings were helpful in enhancing the RNs’ knowledge of safely preparing medications for their patients, but also that observer bias was present during the observations.

Conclusions: Although it appears that the specific aim was met, only 10 observations were collected. Additionally, the presence of observer bias interfered with the data collection process, indicating that the results do not reflect the actual practices of the RNs. However, the responses from the survey indicated that the intervention efforts did enhance the RNs’ knowledge of safe medication practices and identified the need to improve access to the eMAR throughout the microsystem.

Included in

Nursing Commons