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The use of a standard design medication room to promote medication safety: organizational implications

H. Rozenbaum, L. Gordon, M. Brezis, N. Porat
DOI: http://dx.doi.org/10.1093/intqhc/mzt005 188-196 First published online: 18 January 2013

Abstract

Quality problem Medication administration is one of the most potentially dangerous tasks in hospitals. In recent years, the medical establishment has gained insight into the importance of environmental and ergonomic factors on patient safety. Limited data are available on how a standard designed medication room (MR) supports safety medication administration.

Initial assessment Proactive observations were conducted at a tertiary care facility, the Hadassah University Medical Center, Jerusalem, Israel, to determine if safety principles were being implemented in the medication preparation and storage environment. These observations revealed that no designated MRs existed in the hospitals wards and safety systemic weaknesses in medication preparation.

Choice of solution Guidelines for planning and designing MRs, based on safety and human engineering principles, were established to promote safer medication administration in hospital wards.

Implementation The purpose of the survey was to compare the implementation of safety principles among hospital wards before and after MR renovation and among hospital wards with and without a MR. Structured observations in medication preparation areas and storage were designed. Selected safety indicators were measured (e.g. ordering and labeling; storage of intravenous infusions). Each category was subdivided into indicators that were design dependent only (DD), design and behavior dependent (DBD) and behavior dependent only (BD).

Evaluation Indicators that were both DD and DBD showed significant improvement before and after renovation of MRs. Most of the results were not significant for BD indicators. A similar trend was observed in departments with and without a MR. A trend of improvement could be seen in BD-positive indicators, regardless of the presence or absence of a dedicated MR.

Lessons learned A standard design MR can improve environmental aspects of safety medication administration.

  • medication room
  • safety
  • design

Introduction

Medication administration is one of the most potentially dangerous tasks in hospitals [15]. Preventing medication errors is an issue that concerns medical service providers worldwide [6, 7]. In recent years, the medical establishment has gained insight into the importance of the many environmental factors influencing patient safety. These factors include: noise, air quality, lighting, work interruptions, equipment and facility design [814]. Joseph and Rashid [11] claimed that inappropriate environmental design increases risk factors for error (e.g. fatigue, stress, burnout and lack of compliance with procedures). Appropriate environmental design takes error prevention into account and plays a critical role in preventing catastrophic hospital errors. Poor design, on the other hand, does not take error prevention into account and results in significant increased risk to patients [15]. Straucher et al. [16] found that an ergonomic, dedicated medication room (MR) reduces the risk of medication errors. An appropriately designed and organized MR was found to be a safety strategy for medication error prevention. Conrad et al. [17] describe a departmental medication safety project to improve the physical design and organizational layout of the MR, reduce nurse interruptions and create standard medication administration process for enhanced efficiency and patient safety. This project meets the safety guidelines of leading organizations such as the United States Pharmacopeial (USP) Convention [18] and the Joint Commission [19]. Still, limited data are available on how hospitals implement safety principles in MRs and how dedicated MRs support safety medication administration [14].

Quality problem or issue

No standard policy existed for medication preparation and storage at the Hadassah University Medical Center in Jerusalem. For many years, medication preparation was done in areas near the nurse station, with no provision for safety and ergonomic issues.

Initial assessment

The Committee for Quality and Medication Safety (CQMS) at the Hadassah University Medical Center, a multidisciplinary committee comprising nurses, physicians, pharmacists, computerized information systems, risk management and management representatives, conducted proactive observations to determine if safety principles were being implemented in the medication preparation and storage environment.

These observations revealed that no designated MRs existed in the hospitals wards. The committee members documented systemic weaknesses in medication preparation (e.g. improper medication storage, noise and the lack of both work surfaces and air conditioning). Medication was prepared in such areas as the nurse station or multipurpose room. The committee recommended that there should be a dedicated MR in each clinical unit. Accordingly, the CQMS formulated standard guidelines for the plan and design of MRs, with the aim of improving medication safety.

At the time the surveys were conducted, there was no computerized physician order entry system, electronic medication administration record or unit dose in either hospital.

The central pharmacy provides the medications needed for each department according to its medication list and special needs. Every clinical unit has a dedicated medication storage area. Every department has access to computerized reference information such as Micromedex, and a non-clinical departmental pharmacist was available for consultation.

Clinical pharmacists, who review the physicians' medications orders, are present only in the internal medicine wards.

Choice of solution

The CQMS's first step was to formulate guidelines for the plan and design of MRs, based on safety and human engineering principles [8] and supported by leading bodies such as the USP [18] and the Joint Commission [19].

The guidelines were to include detailed instructions for the physical design of a MR, with the aim of improving ergonomic safety and reducing interruptions and distractions. The decision was made to include CQMS members, the ward head nurse, a clinical pharmacist, the medical director, an architect and other relevant partners (e.g. an infection control team), when necessary, in every design or renovation of the ward MR. A set of standards were developed and applied to the MR plan. The multidisciplinary team collaboration enabled application of these standards to any type of medical unit.

The guidelines included the following principles:

  • ‘Designated MR’: the sole use of the MR will be for drug preparation, storage and medication carts. No other equipment will be permitted (e.g. urine catheters, nasogastric tubes, sterile trays). The room will be a distraction-free space for medication preparation by the nursing staff.

  • ‘Security’: The entrance door will be an electrically controlled and semitransparent sliding door, allowing for the observation of the ward during the preparation process. Only authorized staff will have access with a personal magnetic card.

  • ‘Human engineering aspects’: the architectural design should include optimal lighting and air quality, optimal height work surfaces and easy access to modular storage, allowing for adjustment to changing needs and free, clear space. In addition, every MR should have a clock, bulletin board and bookshelf for relevant medication information, as well as a computer station.

  • ‘Infection control’: it is forbidden to store food, body fluids, excrement or sample containers in the MR. A designated area is being planned for storage of these items. Every MR should have an electric-eye-operated faucet, antimicrobial liquid hand soap, alcohol-based hand rub solution, paper towels, a garbage device for sharp objects and a trash bin, as stated in the infection control unit's guidelines.

  • ‘Appropriate storage of drugs and related equipment’: a standard drug and intravenous solution list will be defined for each department. Drugs will be arranged by the mode of administration (injection, oral and external). Each form will be arranged by its alphabetic generic name, and every type of drug and dosage will have its own cell. In addition, equipment storage required for drug administration (e.g. medications labels, gloves, needles and syringes) will be carried out in a dedicated place. The standard drug refrigerator will have a transparent door and dedicated cells for arranging drugs according to the same principles. Intravenous infusions will be stored on pullout open shelves. Each type of infusion should be stored in its original box to allow for a first in/first out storage. The manufacturer's label with the critical infusion information should be visible on the front of the box.

  • ‘Storing controlled substances’: all narcotics will be stored in a dedicated bank-like safe. The safe will be linked to the security division and can only be opened by an authorized personnel with a magnetic card. Computerized records of date, hour and staff member can be obtained when needed.

  • ‘Storage of concentrated electrolytes for IV use’: strong potassium chloride, sodium chloride 3%, mannitol 20%, dextrose 20%, dextrose 50%, if rarely used, should be removed from the ward MR. Concentrated electrolytes will be stored in closed, specially designed, separated cells and with warning labels. Strong potassium chloride for intravenous injections, in particularly, will be stored in green cells.

  • ‘Storage of high-risk medications for IV use’: Designated color-coded labels for intravenous high-risk medication will be stored in the medications cells (the medication list was determined by the Ministry of Health). Designated color-coded labels for different lines will be stored in a special device on the work surface in the MR [20].

Implementation

The Hadassah Hospital administration approved these procedures and decided to allocate the necessary resources for the renovation and construction of dedicated MRs, as a safety strategy approach.

From 2003 through 2010, 32 new MRs were renovated or constructed according to these principles. It was necessary at times to make intelligent compromises (e.g. adjustment of the MR's standard to a given room size and environmental conditions).

Evaluation

Objectives

  1. To compare the implementation of safety principles among hospital wards, before and after the renovation of MRs (2005 versus 2008).

  2. To compare the implementation of safety principles among hospital wards, with and without MRs at a single point in time (2008).

Methods

This structured observation survey was based on observations in medication preparation areas and storage. The sample method was based on concurrent controls. Wards without a MR were observed by investigators at the same time as the wards with a MR. However, this was not done using random assignment of MRs to control and intervention groups—all departments in both hospitals were sampled. The observations were carried out by pharmacists, pharmacy student interns and the members of the CQMS, who received training in conducting the survey. Two surveys were conducted; one in 2005 and the second in 2008.

Survey design

The questionnaire included:

  1. Setup and labeling in the medication storage area (e.g. presence of pharmacy-printed labels for each drug cell; presence of more than one drug per storage cell).

  2. Storage of IV infusions (e.g. sodium chloride 0.9%).

  3. Refrigerated drug storage.

  4. Work environment (e.g. lighting, air quality, clean and free work surfaces).

  5. Infection prevention (e.g. presence of blood or urine samples).

  6. Behavioral parameters.

Below are examples from the questionnaire:

View this table:

Several questions had ‘partial’ as an answer in addition to ‘yes’ and ‘no’. ‘Partial’ meant that at times, not all the findings on a particular question were according to the standards. For example, answering ‘partial’ to the question ‘presence of pharmacy-printed labels with Latin letters for each drug cell’ meant that some of the cells had pharmacy-printed labels with Latin letters and some did not.

Sample

Setting

The study was conducted in two Hadassah-Hebrew University Medical Center hospitals in Jerusalem, Israel: the Ein Kerem (EK) campus and the Mount Scopus campus. Hadassah Ein Kerem is an 800-bed hospital that opened its doors in 1961. EK serves the Jerusalem population as both a general and specialty hospital and as a referral center for the entire region. Hadassah Mount Scopus is a 300-bed community hospital, serving the Jewish and Arab populations of northern and eastern Jerusalem, that was renovated and reopened in 1975. The more complex cases in need of specialty care (e.g. transplantation, oncology, cardiovascular procedures and neurosurgery) are referred to EK.

The 2005 survey included 45 departments at the Hadassah Ein Kerem Medical Center and 22 departments at the Hadassah Mount Scopus Medical Center. The 2008 survey included 53 departments in Ein Kerem and 25 departments in Mount Scopus.

Between 2005 and 2008, 15 departments were renovated with new standard MRs and met the study criteria. During this period, the organizational structure of a few departments was changed—some were merged and others were created.

Table 1 details the type of wards with and without a MR in the 2008 survey.

View this table:
Table 1

Type of wards with and without a MR in the 2008 survey

Type of wardsNumber of wards without MR (control group)Number of wards with MR (study group)
Internal medicinea84
Surgerya183
ICU93
Oncologya73
Pediatrica53
Maternity23
Delivery room11
Emergency room23
Other (psychiatry, rehabilitation and hospice)12
Total2553
  • aIncluding day care.

Statistical methods

All data analysis was done using the SPSS predictive analytics software version 15, NY, USA.

A P-value of < 0.05 was considered significant.

Outcome categorical variables were analyzed using Pearson's Chi-square Test of association. In cases, where the cross tabulation cells contained small sample size (usually less than five responses), Fisher's exact test was used.

The independent t-test for pairs was run to test the significance between means in the first and second surveys.

Table 2 shows the safety status classification for each indicator in the questionnaire by comparing the results of 2005 and 2008. The results were defined as ‘better’, ‘unchanged’ or ‘worse’ in the second survey when compared with the first.

View this table:
Table 2

Safety status classification for each indicator in the questionnaire by comparing the results of 2005 and 2008

Result in 2005Result in 2008Safety status classification
NoYesBettera
NoPartialBettera
PartialYesBettera
YesYesBettera
NoNoUnchanged
PartialPartialUnchanged
YesNoWorse
YesPartialWorse
PartialNoWorse
  • aMaintaining the level of achievement reflects ongoing positive action and, therefore, was defined as ‘better’.

For example, if in the first survey, the answer to the question ‘Presence of pharmacy-printed labels in Latin letters for each drug compartment’ was ‘No’ and in the second survey, it was ‘Yes’—the change was defined as ‘Better’. Table 2 details all the result possibilities of the classification.

The non-parametric sign test was used with paired data to determine if there was a change, the direction of the change and whether the change was significant.

The delta (Δ) value in Table 5 was the difference in percentage between wards with and without MR. A greater delta value in one group meant that the safety indicators were better in that group. When no delta value was indicated, it meant that the gap between wards with an MR and those without an MR was negligible.

Results

Table 3 shows the distribution of the study observations in hospital wards, before (first survey in 2005) and after renovation (second survey in 2008) of MRs, by the following categories: ordering and labeling in the medication storage area; storage of IV infusions; drug storage in the refrigerator and work environment. Each category was subdivided into: indicators that were fully design dependent (DD); indicators that were design and behavior dependent (DBD) and indicators that were solely behavior dependent (BD).

View this table:
Table 3

Evaluation of safety indicators among hospital wards, before and after MR renovation (2005 versus 2008)

Safety indicatorsBetter % (n)Unchanged % (n)Worse % (n)P-value
Ordering and labeling medication storage area
DDSeparation of solutions and ointments for external use100 (12)00<0.0001
Pharmacy-printed labels in Latin letters for each drug compartment100 (14)00<0.0001
PO medications arranged alphabetically by generic name100 (13)000.0001
DBDMore than one dosage of the same drug per storage compartment85 (11)015 (2)0.022
More than one drug per storage compartment100 (14)00<0.0001
BDPartial tablets in drugs compartment69 (9)031 (4)NS
KCL: syrup bottle is closed with the original cap9 (1)90 (10)(0)NS
Optalgin: syrup bottle is closed with the original cap8 (1)92 (12)(0)NS
Salbutamol: date opened is written on the bottle(0)100 (9)(0)NS
Itrapropium: date opened is written on the bottle10 (1)90 (9)(0)NS
Insulin Actrapid: date opened is written on the bottle89 (8)11 (1)(0)0.039
Storage of IV infusions
DDPharmacy-printed labels in Latin letters for each drug compartment78 (11)22 (3)00.001
Presence of other IV infusions in normal saline 0.9% IV infusion compartment100 (13)00<0.0001
Strong potassium chloride for injection is stored in separate area from other IV drugs100 (7)000.016
Drug storage in refrigerator
DDPresence of pharmacy-printed labels in Latin letters for each drug compartment53 (8)40 (6)7 (1)0.039
BDOnly drugs stored in refrigerator53 (8)33 (5)14 (2)NS
The refrigerator is clean100 (14)000.0001
Other safety indicators
DDStorage labels device are present93 (14)7 (1)0<0.0001
Hooks for IV infusions are present100 (15)00<0.0001
Work surfaces are free of unnecessary equipment93 (14)7 (1)0<0.0001
Non-related equipment for medication administration is stored in the MR80 (12)7 (1)13 (2)0.013
BDThe mortar is clean57 (4)14 (1)29 (2)NS
  • n, Number of wards. DD – Design Dependent, DBD – Design & Behavioral Dependent, BD – Behavioral Dependent.

There is a significant improvement before and after the renovation of MRs in all indicators that are DD and DBD. Most of the results are not significant in indicators that are only BD.

It should be noted that there was also a significant improvement in most of the indicators in wards without MR in the second survey when compared with the first (Table 4).

View this table:
Table 4

Evaluation of safety indicators among hospital wards that did not undergo MR renovation (2005 versus 2008)

Safety indicatorsBetter % (n)Unchanged % (n)Worse % (n)P-value
Ordering and labeling medication storage area
DDSeparation of solutions and ointments for external use90 (38)2 (1)7 (3)<0.0001
Pharmacy-printed labels in Latin letters for each drug compartment74 (34)11 (5)15 (7)<0.0001
PO medications arranged alphabetically by generic name74 (34)24 (11)2 (1)0.0001
DBDMore than one dosage of the same drug per storage compartment70 (30)2 (1)28 (12)0.009
More than one drug per storage compartment69 (31)2 (1)29 (13)0.01
BDPartial tablets in drugs compartment63 (27)7 (3)30 (13)0.04
KCL: syrup bottle is closed with the original cap100 (33)0 0<0.0001
Optalgin: syrup bottle is closed with the original cap98 (41)0 2 (1)<0.0001
Salbutamol: date opened is written on the bottle17 (5)72 (21)10 (3)NS
Itrapropium: date opened is written on the bottle23 (7)73 (22)3 (1)NS
Insulin Actrapid: date opened is written on the bottle72 (18)8 (2)20 (5)0.011
Storage of IV infusions
DDPharmacy-printed labels in Latin letters for each drug compartment67 (29)12 (5)21 (9)0.002
Presence of other IV infusions in normal saline 0.9% IV infusion compartment88 (37)012 (5)<0.0001
Strong potassium chloride for injection is stored in a separate area from other IV drugs74 (20)15 (4)11 (3)<0.0001
Drug storage in refrigerator
DDPresence of pharmacy-printed labels in Latin letters for each drug compartment43 (20)41 (19)15 (7)0.021
BDOnly drugs stored in refrigerator39 (18)46 (21)15 (7)0.043
The refrigerator is clean97 (37)03 (1)<0.0001
Other safety indicators
DDStorage label devices are present64 (23)19 (7)17 (6)<0.003
Hooks for IV infusions are present44 (15)15 (5)41 (14)NS
Work surfaces are free of unnecessary equipment76 (31)7 (3)17 (7)<0.0001
Non-related equipment for medication administration is stored in the MR74 (26)9 (3)17 (6)0.001
BDThe mortar is clean71 (15)5 (1)24 (5)0.041
  • n, Number of wards. DD – Design Dependent, DBD – Design & Behavioral Dependent, BD – Behavioral Dependent.

Table 5 shows the distribution of the study observations in hospital wards, with and without MRs (2008), by the same categories and variables as shown in Tables 3 and 4. In the second survey, a few more indicators were added, due to experience gained on staff behavior in the dedicated MRs.

View this table:
Table 5

Evaluation of safety indicators among hospital wards, with and without a MR (2008)

Safety indicatorsWards with MRWards without MRΔP-value
% (n)% (n)Wards with MRWards without MR
Ordering and labeling medication storage area
DDSeparation of solutions and ointments for external use92 (24)85 (46)7NS
Presence of pharmacy-printed labels in Latin letters for each drug compartment82 (27)72 (50)10NS
PO medications arranged alphabetically by generic name100 (26)68 (50)320.001
DBDMore than one dosage of the same drug per storage compartment80 (25)61 (46)19NS
More than one drug per storage compartment89 (26)71 (48)18NS
BDPartial tablets in drugs compartment68 (17)63.8 (30)4.2NS
KCL: syrup bottle is closed with the original cap100 (21)97.2 (35)2.8NS
Optalgin: syrup bottle is closed with the original cap96.2 (25)95.8 (46)0.4NS
Salbutamol: date opened is written on the bottle0 (0)29.3 (12)29.30.006
Itrapropium: date opened is written on the bottle5 (1)35.9 (14)30.90.011
Insulin Actrapid: date opened is written on the bottle66.7 (12)71.4 (20)4.7NS
Furosemide strips are intact (no cutting of individual pills in package)a54.5 (12)55.6 (20)1.1NS
Amlodipine strips are intact (no cutting of individual pills in package)a52.9 (9)50 (16)2.9NS
Ciproxine strips are intact (no cutting of individual pills in package)a68.4 (13)54.2 (13)14.2NS
Omeprazole strips are intact(no cutting of individual pills in package)a60 (12)63.2 (24)3.2NS
Storage of IV infusions
DDPharmacy-printed labels in Latin letters for each drug compartment82 (22)70 (32)12NS
Other IV infusions in normal saline 0.9% IV infusion compartment100 (26)89 (40)11NS
Strong potassium chloride for injection is stored in a separate area from other IV drugs100 (20)67 (26)330.029
Drug storage in refrigerator
DDPresence of pharmacy-printed labels in Latin letters for each drug compartment37 (10)31 (15)6NS
BDOnly drugs stored in refrigerator48.1 (13)37.5 (18)10.6NS
The refrigerator is clean100 (24)97.6 (41)2.4NS
Other safety indicators
DDStorage label device is present96.3 (26)64.1 (25)32.20.002
Hooks for IV infusions are present96 (27)64 (39)320.002
DBDWork surfaces are free of unnecessary equipment82 (27)61 (43)21NS
Non-related equipment for medication administration is stored in the MR34 (27)7 (38)270.016
Urine test kits are present in the MR (forbidden)a8 (26)20 (40)12<0.001
Glucose test kits are present in the MR (forbidden)a16 (25)57 (42)410.001
BDThe mortar is clean34.6 (15)65.4 (24)30.8NS
  • n, Number of wards. DD – Design Dependent, DBD – Design & Behavioral Dependent, BD – Behavioral Dependent.

  • aQuestions appearing in survey 2 only.

In all the indicators that are DD and DBD, there is a significant improvement or positive trend of improvement in departments with a MR when compared with departments without a MR. In indicators that are BD, a positive trend of improvement can be seen regardless of the presence or absence of a dedicated MR.

Lessons learnt

We described a cross-organizational process to promote medication safety. This process was facilitated by detailed guidelines for planning and renovation of MRs.

This article presents research findings from two perspectives. The first perspective compares safety principles implementation among hospital wards with MR (Table 3) and without MR (Table 4), between two periods of time (2005 versus 2008). The findings show significant improvement in all DD- and DBD-examined parameters, but inconsistent results in the BD parameters. The changes among wards without MR (Table 4) are probably related to hospital-wide changes. In light of the change in wards with renovated, dedicated MRs, staff members in wards without MR attempted to find solutions to promote safety in their medication preparation area. These findings reflect the importance of organizational intervention in implementation of safety culture, particularly in the area of medication administration.

The second perspective evaluates the same intervention at one point in time. The findings (Table 5) show a similar trend as seen in Tables 3 and 4. This table reflects a positive trend and sometimes significant improvements in departments with MR when compared with those without MR. It should be noted that the 2008 survey sample of wards with MR is larger and reflects a situation at one point in time when compared with a timeline evaluation.

These results indicate that a dedicated MR, designed with a combination of safety and ergonomic principles, compels safety behavior in medication administration and promotes safety culture.

It may seem obvious that organization creates order. However, this study emphasizes the importance of design to compel safety behavior. In instances, where behavior alone is a determinant of safety, outcomes can be less satisfactory. This concurs with the literature that emphasizes the significant contribution of human engineering factors to environmental design in reducing errors and promoting employees' welfare [913, 16]. Where the design does not compel safety behavior, departmental cultural and behavioral norms are expressed. This emphasizes the limitations of planning dedicated MRs on safety behavior in medication administration. Ben-Ami et al. [21] emphasize the importance of management's role in identifying barriers that interfere with a medical team's response to safety guidelines, in promoting activities to reduce or to remove these barriers and in providing suitable conditions to allow for compliance with these guidelines. Following this approach and as a result of our study findings, supplemental guidelines were established for the daily behavior of staff members in the MR. These guidelines are presented to the staff during training programs. They detail the authority and responsibility of the departmental head nurse and pharmacist, lay out principles for storage and management of the medication inventory in the ward, orientation in the MR by medications forms and order by alphabetically generic names, safety medication administration, infection control and maintenance of a clean and organized work environment.

Limitations

This study has potential biases associated with the non-randomized and non-blind design. A change in the ‘before’ and ‘after’ observations deriving from institutional improvement in safety culture was seen as a trend of improvement in the concurrent controls, and yet, the presence of a MR appeared to have an effect over and above this trend (Table 3). The study did not evaluate outcomes such as patient safety or cost-effectiveness. The sample is small and included only two hospitals in a work setting that may not apply to other medical centers. Also, changes in safety culture that are coupled with the effect of improved infrastructure may be expressed differently in dissimilar institutions [22].

Conclusion

This feasibility study shows that from a safety point of view, there are benefits from planning standard designated MRs. A systematic approach can improve environmental aspects of safe medication administration. Moreover, it is important to accompany this process with appropriate staff education and ongoing evaluation, to promote and assimilate an organizational safety culture.

Conflict of Interest statement

All authors declare that the answers to the questions on the journal's competing interest form are all ‘No’ and, therefore, they have nothing to declare.

Funding

No author has any direct or indirect commercial financial incentive associated with publishing of this article. We had no funding sources for this research. We affirm that no funding agreement limits our ability to complete and publish our research/study and we had complete control of primary data.

Acknowledgements

We would like to thank the members of the CQMS, the head nurses, the medical directors and the pharmacists at the Hadassah Medical Center who participated in promoting this project and survey. The authors are grateful to Prof. Leon Gordis for his constructive remarks and to Mr Amir Urson for helpful advice.

References

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