Understanding Variation - How We Fixed The Unstable Medication Administration Process

Anne Lloyd - Director of Nursing

Westhaven Nursing Facility, located in Roma, Central Queensland, is part of the Queensland Health group of residential aged care facilities and has been participating in the QPS Benchmarking program for approximately four years. Each time the QPS Benchmarking Staff Medication Audit is undertaken the results are analysed and all strategies implemented to achieve improvements are reviewed for their effectiveness.

Interpreting Our Results

What became evident over time was both the trend and benchmarked results were showing significant variation being reported each time the audit was being undertaken. To ensure we were interpreting the data and results correctly we made sure we reviewed our trends over a period of time and we also could see that when entering our data on line for the QPS Benchmarking, our results were above and then below our upper and lower control limits. So what does this mean? When you experience these types of results and see this pattern occurring, it is telling us that our process for administering medications is very unstable. In more practicals terms it means that sometimes the staff responsible for administering medications follow the procedure very well and at other times it is not followed according to expected standards.


Problem Solving

The variation in the results provided an opportunity to improve the management and administration of medications and a review of the current system and processes in place were undertaken. There was also a focus on understanding the reasons and associated causes for the variation in the results when errors where being made.

Examples of causes identified included:

• Disruptions to nurses' concentration due to the TV being on (and usually loud) and the radio also on in the Kitchenette.
• Interruptions by staff to licensed nurses while administering medications.
• Constant phone calls to licensed staff during administering of medication.

The above distractions all contributed to a decreased ability to concentrate and focus on the required process and duties.

Other issues identified included;

• A single dose pre packed system was being used and due to the simplistic nature, it became easy to become complacent with the administration and signing of medications.
• As long as the medication was in a pre-packed device, it was given. No real concern for what the medication is used for, and not linking the knowledge of the medication to its administration.
• The general thinking of "If the medication is missing from the pre packed device, then it was administered", despite no signature on the medication sheet.
• Financially, having medication packed each and every month was a large expense for the facility.

Introducing Change

Introducing change to a well-established system can prove very challenging and this was recognised by both the management and staff at Westhaven. There was also an understanding that to be successful, this improvement opportunity had to be embraced by all stakeholders and this was communicated to all staff responsible and involved in the medication administration process. Once this commitment was gained from the team, the decision was made to take the next step in the challenge.

One stakeholder in the process, the local pharmacy (the only one in town) was happy to work with the facility in planning the changeover. This collaboration between the facility and pharmacy worked on many issues that arose within the ordering and supply processes, with constant feedback provided to the pharmacy. A progress meeting was held with the pharmacy midway through the changeover to discuss any areas of concern and the receptiveness and patience of the pharmacy was appreciated by all involved.


A date was set for the change and it was decided to implement the change in steps. There are four wings within Westhaven and the new medication system was implemented one wing at a time each month. This meant the implementation process took four months to complete.

Clear direction was given to licensed nurses, that this system would be reliant on their cooperation. Licensed staff are to wear medication vests, television and radio off, no telephone and no other staff talking to RN/EEN while administering medication. This was not a negotiable process and it required a persistent approach till staff became accustomed to the new system. Diligence, diligence, diligence in adhering to the system was constantly reinforced.

Monthly audits of medication charts were conducted to identify non signings to measure our progress. Several strategies were tried to improve signing of medication charts and achieve compliance. The naming of staff responsible for not signing created its own issues. The number of non signings was put on the agenda for the monthly licensed nurses' meeting. The impact of non signings on accreditation and/or unannounced and announced site visits from the aged care standards and accreditation agency were highlighted. This had to be put in real terms "will you be here when the agency visit to respond to the non signings".

This has not been an overnight success for the facility and it certainly has been a change of process for all to get used to. However, our licensed nurses now don their medication vests at the commencement of each medication round. Our AIN staff will wait to advise the registered nurse of any resident issues, except in cases of emergency, of course. Commitment from all staff was required to ensure the process was working and it took some time for it to become second nature.

Concerns raised by licensed nurses, that the new system would be a timely process, thankfully proved incorrect. It has been proven, within Westhaven, to have no impact on time at all. Our licensed nurses are happy with the system and have provided positive feedback. All our staff have to be congratulated for their commitment to resident care, the facility, improving the service provided and striving for excellence.

Achieving Excellence