| Course | NUR-3220 Fundamentals of Nursing |
|---|---|
| Module | Module 4 |
| Paper type | Nursing paper: medication administration safety |
| Length | About 1,017 words, 6 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | B.S.N., Accelerated Second Degree |
| Updated | October 2026 |
Free sample paper for NUR 3220 Module 4
Eleven Interruptions Before Ten O'Clock: Making a Student's Medication Pass Safer on a Camden Surgical Unit
Student Name
B.S.N., Accelerated Second Degree, Thomas Edison State University
NUR-3220: Fundamentals of Nursing
Mentor Name
Month Day, Year
Eleven Interruptions Before Ten O'Clock: Making a Student's Medication Pass Safer on a Camden Surgical Unit
The Morning
None of the people or places here is real. On a 30-bed surgical unit at a hospital in Camden, a BSN student gave morning medications to two patients under her instructor's supervision. Between 0800 and 1000, she was interrupted eleven times: a call light, a family member asking about discharge, a technician asking where to find supplies, a phone call from the lab about another nurse's patient, the instructor asking a question and several others. During one interruption she set down a cup of pills for one patient beside the other patient's tray. Her instructor noticed before anything was given. The student was shaken and asked how experienced nurses avoid such errors.
Interruptions and Errors
Westbrook et al. (2010) observed nurses at two teaching hospitals during thousands of medication administrations. Interruptions occurred in about half of administrations. Each interruption was associated with an increase of about 12 percent in procedural failures, such as failing to check a patient's identification, and by about as much in clinical errors, a wrong dose for example. The risk of a major error doubled when a nurse was interrupted four or more times during one administration. Nurses with more experience were not protected from interruption-related procedural failures.
Bar-Code Scanning
Poon et al. (2010) compared medication administration on hospital units before and after bar-code electronic medication administration was introduced, observing thousands of administrations. The rate of non-timing errors, such as wrong dose or wrong drug, fell by about 41 percent, and potential adverse drug events related to these errors fell by about 51 percent. Timing errors also fell. The system has the nurse scan both the wristband and every package, so that a mismatch triggers a warning before the medication is given.
Why Errors Happen
Keers et al. (2013) brought together quantitative and qualitative studies asking why hospital staff make errors when giving medicines. Most errors were slips and lapses, a missed step for instance, rather than lack of knowledge, though knowledge-based mistakes also occurred. Conditions that made errors more likely included interruptions and distractions, heavy workload, staffing problems, poor communication, problems with medicines and equipment and work environments that made safe practice difficult. The authors argued that preventing errors requires attention to these conditions, not only to individual nurses.
| Source | Key finding | Lesson for the student |
|---|---|---|
| Westbrook et al. (2010) | Each interruption raised error risk; four or more doubled major errors | Protect the medication pass from interruption |
| Poon et al. (2010) | Bar-code scanning cut wrong-drug and wrong-dose errors | Scan every patient and every dose |
| Keers et al. (2013) | Most errors are slips and lapses under poor conditions | Change conditions, not only effort |
Strategies for the Student
The student, her instructor and the nurse she was assigned with agreed on several strategies. She prepares one patient's medications at a time and takes them directly to that patient. She scans the wristband and every medication, never overriding a scanner warning without asking her instructor. If interrupted while preparing medications, she says she will help in a moment and finishes the step she is on before stopping, and if she must stop, she returns the medications to the patient's bin. She uses the rights of medication administration as a final check at the bedside: the right patient and the right drug, dose, route, time and charting, with a final question to the patient about what each medicine is for.
What the Unit Tried
The nurse manager, hearing about the student's experience, agreed to a two-week trial of a quiet zone around the medication room from 0800 to 0930, with a sign asking staff not to interrupt nurses preparing medications. Technicians and the unit secretary were asked to direct non-urgent questions to the charge nurse during that time. Nurses noted fewer interruptions, though call lights still came.
Reporting the Near Miss
The instructor asked the student to complete a near-miss report for the pill cup set down beside the wrong tray. The student worried that reporting would count against her, but the instructor explained that the hospital uses near-miss reports to find conditions that make errors likely, and that the report would not be used to discipline her. The report described the interruptions, the shared tray table between two beds and the time pressure of morning medications. The unit's safety committee later noted three similar reports that month, which supported the quiet-zone trial. Reporting turned one student's scare into information the unit could use.
Double Checks for High-Alert Medications
The student also learned the unit's rule for high-alert medications, insulin and heparin among them, which a second nurse must check independently before they are given. An independent check means the second nurse calculates the dose and verifies the order without being told the answer first, so that the first nurse's error is not simply repeated.
Talking With Patients
Asking patients about their medications is itself a safety check. When the student told one patient she was giving metoprolol for blood pressure, he said he took a different heart pill at home. Checking revealed that his home medication list had been entered incorrectly, which the student reported.
What the Student Learned
The student had believed that careful nurses do not make errors. The research showed her that careful nurses make errors when conditions are poor and that safe practice depends on systems that catch slips. She now treats the scanner and the bedside check as protections she relies on, not as tasks to rush through.
Limits
Observational studies show associations, not that interruptions cause every error. Bar-code systems can be worked around, and their benefits depend on consistent use. A two-week trial on one unit cannot show lasting change.
Conclusion
Eleven interruptions nearly led to a wrong-patient error. Westbrook's study showed how interruptions raise error risk, Poon's study showed how bar-code scanning catches errors and Keers's review showed that most errors are slips made under poor conditions. Preparing one patient's medications at a time, scanning every dose, managing interruptions and checking with patients made the student's medication passes safer.
References
Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: A systematic review of quantitative and qualitative evidence. Drug Safety, 36(11), 1045-1067. https://doi.org/10.1007/s40264-013-0090-2
Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115
Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690. https://doi.org/10.1001/archinternmed.2010.65
What the NUR 3220 Module 4 instructions ask for
TESU's catalog paragraph for NUR-3220 calls for nursing principles that support safe practice, and because the course syllabus is reserved for enrolled students, the fourth module is planned as a medication safety paper drawn from a clinical experience. A strong paper describes a real or realistic medication pass, reviews evidence on interruptions, technology and the causes of administration errors, takes a systems view rather than blaming individuals, describes personal strategies and unit-level changes and reflects on what the student learned. Some sections ask for a paper on high-alert medications or on a specific error reported to the unit instead. Check whether near misses from your clinical experience may be described and how to keep patients and staff anonymous, and follow your program's policy on reporting errors.
How this NUR 3220 Module 4 example is built
An invented BSN student interrupted eleven times during a morning medication pass on a Camden surgical unit, and a near miss with a pill cup, open the paper. Westbrook's study of interruptions, Poon's study of bar-code scanning and Keers's review of error causes are explained and summarized in a table. The student's strategies, the unit's quiet-zone trial, a patient's question that revealed a home medication error and the student's reflection follow. The paper names its limits and concludes. Annotations note the systems view of error and the unit's change of conditions. Sections on reporting the near miss and on independent double checks for high-alert drugs show how errors become learning for the unit.
Where the marks sit in the NUR 3220 Module 4 rubric
Medication safety papers are marked up for a believable medication pass, careful reporting of evidence on interruptions, technology and causes of error, a systems view that addresses conditions, specific personal strategies, unit-level changes and reflection. Mentors notice when a student moves from blaming carelessness to understanding slips and lapses. Asking patients about their medications shows understanding of patients as partners in safety. Admitting the limits of observational evidence shows careful reading. Large author lists, such as the bar-code study's, should be reproduced fully in APA style. Completing a near-miss report and explaining why reporting is safe shows understanding of a just reporting culture. Describing an independent double check correctly shows attention to detail.
NUR 3220 Module 4 help from the desk
Medication safety papers often promise to be more careful; describe the conditions that cause slips and the checks that catch them. Another frequent gap is ignoring interruptions, which research links closely to errors. Prepare one patient's medications at a time. Scan every dose. Finish a step before responding to interruptions. Ask patients what their medications are for. Look for unit-level changes. A free first draft of your own medication safety paper is available; send the pass you want to analyze. Report near misses; they help the unit find dangerous conditions. Learn which medications on your unit need an independent double check.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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NUR 3220 Module 4 questions, answered
Where can I find a free NUR 3220 Module 4 sample paper?
The medication safety paper about an invented student's interrupted pass on a Camden surgical unit, from the near miss to the quiet-zone trial, is shown on this page.
Do interruptions cause medication errors?
In Westbrook's observations, every interruption added roughly 12 percent to the chance of an error, and four or more doubled the odds of a serious one.
Does bar-code scanning reduce medication errors?
Poon and colleagues found non-timing errors fell about 41 percent and potential adverse drug events about 51 percent after bar-code administration.
What causes most medication administration errors?
Keers and colleagues found most were slips and lapses made under conditions such as interruptions, workload and staffing problems.
What are the rights of medication administration?
Most lists name six: patient, drug, dose, route, time and documentation, and many nurses add a seventh, checking that the patient knows why the medicine is given.