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Evaluating the Impact of Medication Cabinets in Patients’ Rooms on a Medical-Surgical Telemetry Unit

March-April 2014 • Vol. 23/No. 2 77

Mavel F. Arinal, BSN, RN, CMSRN, is Staff Nurse and Clinical Nurse Educator, Medical- Surgical Telemetry, West Kendall Baptist Hospital, Miami, FL.

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Tanya Cohn, MSN, MEd, RN, is Research Specialist, Center for Research and Grants, Baptist Health South Florida, Miami, FL.

Carmen Avila-Quintana, BSN, RN, CMSRN, is Staff Nurse, Medical-Surgical-Telemetry, West Kendall Baptist Hospital, Miami, FL.

Evaluating the Impact of Medication Cabinets in Patients’ Rooms on a Medical-Surgical Telemetry Unit

M edication administration isa key nurse-driven process.Nurses spend almost 27% of their time on medication-related activities and over 73% of their time on nonmedication-related activities (Keohane et al., 2008). In addition, nurses are responsible for 26%-38% of medication errors in hospitalized patients (Bates, 2007). Nationally, 36% of medication errors occurred in the administration phase (Nation – al Research Council, 2007). Sub – stantial research has been conducted to determine the causes of medica- tion errors and the barriers to report- ing these errors; however, there seems to be little evidence on nurse- initiated and implemented processes to increase medication accessibility, safety, and efficacy.

In April 2011, a 133-bed academ- ic hospital opened in the southeast- ern United States. This facility, the first new nonreplacement hospital in Miami, Florida, in over 35 years, was opened as a patient- and family- centered institution. The study hos- pital has two medical-surgical- telemetry units with 36 private rooms in each unit. Each unit has two medication rooms with individ- ual automated medication dispens- ing systems.

Although the hospital uses bar- coding technology to facilitate safe medication administration, the need to improve this process was consid- ered and implemented through an interdisciplinary shared governance approach among nursing staff, lead- ers, and pharmacy staff. The medica- tion administration process was challenged by the design of the tar- get units. For example, nurses expe- rienced frequent interruptions in

workflow from having to walk down long hallways to the rooms with the central medication dispensing units. Therefore, medication cabinets were installed inside patients’ rooms to help nurses with medication admin- istration. Inside each medication cabinet, nurses were allowed to keep medications due for the shift and other supplies, such as syringes, medication cups, alcohol swabs, and disposable needles, needed for med- ication administration (see Figures 1a-1b). Controlled substances and medications that need to be refriger- ated were not stored in the medica- tion cabinets. The goal of placing medication cabinets in each patient room was to increase accessibility, efficacy, and safety of medication administration.

Literature Review A literature search was conducted

in collaboration with the hospital’s library services using CINAHL and Medline. The search included the years 2006-2012 using different combinations of the following words: medication administration,

medication cabinets, nurse satisfaction with medication administration, and patient outcomes and care. Research was identified regarding medication storage, accessibility, and administra- tion. Gaps identified in the literature included nurses’ perceptions of med- ication safety and efficacy with patient-specific medication storage, as well as how patient-specific med- ication storage may or may not impact medication charge accuracy and medication errors.

Popescu, Currey, and Botti (2010) found ward or unit design influ- enced medication safety and quality. Specifically, the location of medica- tion storage in relation to the patient could have a positive or negative impact on the medication adminis- tration process. For example, the lack of readily available medications increased the risk of late administra- tion or omission. Furthermore, med- ication storage in distant or central storage sites affected medication safety and quality by increasing the number of distractions during med- ication administration. Collection of medications at distant or central storage sites, such as automated dis-

Mavel F. Arinal, Tanya Cohn, and Carmen Avila-Quintana

Results of a pre-post survey study designed to evaluate the impact of medication cabinets in patients’ rooms on nurses’ satisfaction with medication administration, medication charge accuracy, and errors are described.

Instructions for Continuing Nursing Education Contact Hours appear on page 83.

March-April 2014 • Vol. 23/No. 278

pensing cabinets, often requires the nurse to wait in line, which in turn may cause hurried medication selec- tion and medication removal errors (Mandrack et al., 2012).

Using the systematic approach of evaluating failure modes and effects analysis, Hull, Czirr, and Wilson (2010) examined the medication administration process. The authors identified various difficulties related to the storage and administration of medications, including nurses’ frus- tration over making multiple trips to the medication room and waiting in line to use the automated dispensing system. This prompted them to iden- tify workarounds that increased the risk of errors. Specifically, Mandrack and co-authors (2012) reported hav- ing to wait in line increases the likeli- hood nurses will remove more than one patient’s medications at a time. About 30% of nurses reported always or frequently removing more than one patient’s medications at a time. Such work arounds can compromise the safety features of medication administration systems, allowing for new opportunities for error and prob- lematic work practices (Wulff, Cummings, Marck, & Yurtseven, 2011).

Hull and colleagues (2010) placed medication cabinets outside patient rooms and found this intervention decreased the number of times nurs- es went to the automated dispensing

system to retrieve medications. Nurses also reported the location of the cabinets to be more convenient. Although the authors identified increased convenience and decreased time to retrieve medications, they did not evaluate nurses’ perceptions of medication safety and efficacy or the impact medication cabinets may have on medication charge accuracy or medication errors.

Given the evidence related to unit design and nurse workarounds, a collaboration among nursing staff, nursing leaders, and pharmacy staff was initiated in the two medical- surgical-telemetry units where the two medication rooms were a signif- icant distance from most patients’ rooms. The medication cabinet (Enovate Medical; Murfreesboro, TN) was chosen and installed in each patient’s room to simplify the med- ication administration process. All medication cabinets have standard- ized numeric codes for nurse use only to ensure safety and avoid unse- cured medications.

Hypothesis Because nurses are the end users

of the medication administration system, their perception of the process with the use of these medica- tion cabinets was important to the success of this innovative implemen- tation. Authors of this study hypoth-

esized the installation of medication cabinets in the patients’ rooms would increase nurses’ satisfaction with the medication administration process without significant impact on charge accuracy or medication- related errors. Nurses’ satisfaction was defined as the degree to which facility structures and operational policies supported the processes and procedures of delivering medications to patients in a safe but timely man- ner.

Purpose The specific purposes of this study

were to measure nurses’ satisfaction with the medication administration process before and after the installa- tion of cabinets using the Medi – cation Administration System- Nurses Assessment of Satisfaction (MAS-NAS) Scale (Hurley et al., 2006). Three additional questions were developed to expand the effica- cy and safety assessment sections of the MAS-NAS. In addition, hospital data were obtained to determine if the installation of medication cabi- nets in patients’ rooms impacts med- ication charge accuracy or medica- tion errors.

Study Design and Sample

The MAS-NAS Scale (Hurley et al., 2006) was used to compare medica-

FIGURE 1A. Medication Cabinet

FIGURE 1B. Medication Cabinet and Stocked Supplies

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tion administration satisfaction of nurses before and after implementa- tion of medication cabinets. This scale was developed to assist with assessment before and after changes in the medication administration system; pre- and post-implementa- tion data from individual questions can be compared to identify prob- lematic areas perceived by nurses (Hurley et al., 2007). The MAS-NAS includes three subscales: efficacy, safety, and access (see Table 1) (Hurley et al., 2006). Three addition- al questions were included to increase responsiveness and address the intervention of medication cabi- nets (see Table 2). The MAS-NAS also includes seven additional post-inter- vention questions to allow partici- pants to compare the medication administration process before and after intervention. Responses are provided on a 6-point Likert scale from 1 (strongly agree) to 6 (strongly disagree). Two months before instal- lation of the medication cabinets, the MAS-NAS and the three addi- tional questions were distributed during staff meetings. Approxi – mately 2 months after the medica- tion cabinets were installed, data were collected with the same tools plus seven questions to allow partic- ipants to compare the current med-

ication administration process (med- ication cabinets) with the previous medication administration process (no medication cabinets). All 75 direct-care nurses on both day and night shifts of the two units were invited to participate in the study. Before installation, 39 nurses were available for recruitment at staff meetings; 25 (64% response rate) returned completed surveys. After installation, 36 nurses were available for recruitment at staff meetings; 20 (56% response rate) returned com- pleted surveys. In addition, medica- tion charge accuracy data were col- lected through the information tech- nology department, and medication error data from risk management. Parti cipation was voluntary, institu- tional review board approval was obtained, and cover letters were used in the informed consent process. The cover letters included a descrip- tion of the study purpose, necessary actions to participate or not to par- ticipate, and length of study partici- pation; the letters indicated data would be reported in aggregate.

Materials and Methods

Data collection included the MAS-NAS with demographics. The

MAS-NAS previously demonstrated reliability (access alpha=0.71; effica- cy alpha=0.77; safety alpha=0.76; and MAS-NAS alpha=0.86) and validity (efficacy 0.50-0.80, safety 0.42-0.71, and access 0.36-0.74) (Hurley et al., 2006). With the addi- tion of the three questions, internal consistency Cronbach alpha coeffi- cients were calculated for this study (access alpha=0.68; efficacy alpha= 0.83; safety alpha=0.82; and MAS- NAS alpha=0.92). Because all scores, when rounded, were at least 0.7, internal consistency reliability for the scale with the added questions was acceptable.

Medication charge accuracy data (comparison of medication charged to a patient compared to adminis- tered) were collected 1 month prior to installation and implementation of medication cabinets with the assistance of the information tech- nology staff. Medication charge accuracy data were collected 1 month before installation and 6 months after installation of all med- ication cabinets in the two units. Medication error data (number of medication errors) were obtained from the hospital’s risk manage- ment staff. This included 6 months before installation and 6 months after implementation of the medica- tion cabinets. For both charge accu- racy and medication error data, the 2-month implementation period was not included. All data were reviewed and medications that were not authorized to be in the medica- tion cabinets were removed from both data sets (see Figure 2 for study timeline).

Data Analysis All survey data were entered into a

spreadsheet for review and then exported into SPSS 19.0 (IBM Corp., Armonk, NY)) for analysis. All data were converted to the same scale based on question wording, and the subscale scores were calculated based on the MAS-NAS criteria. Descriptive statistics were calculated for demo- graphics of both data collection peri- ods as well as the seven additional questions on the post-installation survey (see Tables 3 and 5). Inde –

Evaluating the Impact of Medication Cabinets in Patients’ Rooms on a Medical-Surgical Telemetry Unit

TABLE 1. Medication Administration System-Nurses Assessment of Satisfaction

(MAS-NAS) Scale’s Subscales

Efficacy: Dependable and effective system

Safety: System components assure nurse that it is correct to administer the med- ication.

Access: Having necessary information and medications immediately at hand

Source: Adapted from Hurley et al. (2006).

TABLE 2. Additional Survey Questions by Subscale

Efficacy: The current system helps me to be time efficient at medication administra- tion.

Efficacy: The current medication administration system allows simple and hygienic storage of medication.

Safety: The current medication administration system helps keep the number of dis- tractions I encounter low.

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pendent t-tests were performed to compare sample demographics, sub- scale scores, and individual ques- tions. Individual item questions were also compared before and after implementation to examine prob- lematic areas that the medication cabinets may have addressed. Charge accuracy data were compared by trending proportions and calculating a z-score using Stat 12.0. Medication error data were compared for differ- ences using independent t-tests ana- lyzed by SPSS 19.0.


The comparison of group demo- graphics before and after installation are summarized in Table 3. No statis- tical significance was found (p=0.05), suggesting the two independent groups were similar demographical- ly. The comparison of the three sub- scales access (p=0.361), efficiency (p=0.229), and safety (p=0.388), along with the total score (p=0.301), did not show a statistically signifi- cant change in survey results before

and after cabinet installation. Com – parison of results for the three sub- scales did not show statistical signifi- cance, but individual questions within the MAS-NAS also were eval- uated (see Table 4). Nurses’ satisfac- tion increased after installation of cabinets based on responses concern- ing availability of equipment and/or supplies needed to administer med- ications (t(42)= 2.057, p=0.046, eta squared 0.09). The effect size of 0.09, a moderate effect, suggests clinical significance. The seven additional

FIGURE 2. Study Timeline

Before Installation of Medication Cabinets Installation Period

After Installation of Medication Cabinets

June 2001 – November 2011

Medication Error Data Collection

Medication Error Medication Charge Accuracy Data Collection

Medication Charge Accuracy data


December 2011- January 2012 February 2012 – July 2012

Variable Before (n=25) After (n=20) p Values

Sex Female 95.7% (22) Female 88.9% (15) 0.35

Male 4.3% (1) Male 11.1% (2)

Age 34.27±8.51 32.29+7.43 0.45

Highest RN degree AS/AD 41.7% (10) AS/AD 33.3% (6) 0.52

BS/BSN 50% (12) BS/BSN 61.1% (11)

MS/MSN 4.2% (1) Diploma 5.6% (1)

Years as RN 3.50 (2.15, 9.50) 3.50 (2.75, 7.0) 0.71

Hours worked per week 37.13±4.23 38.76±6.46 0.33

Shift 7A-7P 50% (12) 7A-7P 55.6% (10) 0.66

7P-7A 45.8% (11) 7P-7A 44.4% (8)

7A-7P & 7P-7A 4.2% (1)

TABLE 3. Sample Demographics

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Evaluating the Impact of Medication Cabinets in Patients’ Rooms on a Medical-Surgical Telemetry Unit


Before (n=25)

Mean (SD)

After (n=20)

Mean (SD) p Value Effect Size

1. Because of information available through the current medication administration system, I know both the intended actions and side effects of medications I administer.

1.78 (1.51) 1.45 (0.69) 0.35 0.02

2. I find the drug alert feature (drug/drug or drug/food interaction) of the current medication administration system helpful.

1.96 (1.58) 1.25 (0.44) 0.05 0.09

3. The current medication administration system makes it easy to check active medication orders before administering medications.

1.43 (0.59) 1.25 (0.55) 0.30 0.03

4. The current medication administration system provides me with information to know a medication order has been checked by a pharmacist before I administer the medication.

1.77 (1.19) 1.45 (0.69) 0.30 0.03

5. The current medication administration system promotes two-way communication between clinicians (MD, pharmacist, RN) about medication orders.

1.70 (0.82) 1.79 (0.98) 0.74 0.003

6. I have access to the systems that support medication administration (physician’s orders, drug information) when I need them.

1.67 (1.01) 1.65 (0.81) 0.95 0.01

7. The drug information available through the current medication administration system is easy to get when I need that information.

1.91 (1.20) 1.53 (0.61) 0.21 0.04

8. When I see a message that acknowledges and accepts a known drug/drug interaction, I know that both physician and pharmacist communicated and agreed on the order.

2.38 (1.58) 1.85 (0.93) 0.20 0.04

9. I know where all the medications I need are stored (either on the unit or if they need to be procured from the pharmacy).

1.92 (1.18) 1.55 (0.76) 0.24 0.03

10. The current medication administration system helps me to be efficient at medication administration.

1.78 (0.90) 1.45 (0.61) 0.17 0.04

11. The current medication administration system makes it easy to check that I am following the “5 rights” when I administer medications.

1.54 (0.78) 1.30 (0.47) 0.21 0.04

12. The turnaround time for receiving medications needed “stat” or for patients newly admitted to the unit is adequate.

2.36 (1.44) 2.35 (1.14) 0.98 0.00

13. The current medication administration system is effective in reducing and preventing medication errors.

1.60 (0.82) 1.30 (0.47) 0.13 0.05

14. The current medication administration system is user friendly to the nurses who administer medications.

1.92 (0.91) 1.55 (0.61) 0.13 0.05

15. The equipment and/or supplies needed to administer medications are readily available to me.

2.08 (1.18) 1.50 (0.51) 0.05 0.09

16. Information available through the current medication administration system helps me to know what to do should my patient have any bad reactions from a medication.

2.57 (1.56) 2.05 (0.95) 0.19 0.04

TABLE 4. MAS-NAS Survey Results

continued on next page

March-April 2014 • Vol. 23/No. 282

post-implementation ques tions showed in creased nurse satisfaction with having the medication cabinets (see Table 5).

Charge accuracy data before and after cabinet installation did not show a statistically significant differ- ence (z=1.33, p=0.1828). The trends of percentage of medications that were both withdrawn (charged) and administered are illustrated in Figure 3. Medication errors 6 months before and 6 months after medica- tion cabinet installation did not show a statistically significant differ- ence (t(10)=0.031, p=0.976).

Discussion Findings indicate medication cab-

inets installed in each patient room increased nurses’ satisfaction con- cerning medication availability. The decision to place medication cabi- nets was driven in part by nurses’ need for more accessible medica- tions and supplies. Data from the post-intervention surveys also sug- gested the medication cabinets allowed nurses to spend more time with their patients and thus increased patient safety. This study’s findings also indicated use of indi- vidual patient medication cabinets did not impact medication charge accuracy or medication errors.

Study Limitations In the initial study design, partic-

ipants were to create a personalized code so researchers could compare individual and group changes before and after installation of the medica- tion cabinets. However, despite simi- larities in demographics, the groups before and after installation did not have the same participants. There – fore, researchers used the independ- ent t-test to compare responses to determine if average perceptions of

the nurses were higher or lower after the installation of the cabinets. In addition to the standard before-and- after questions of the MAS-NAS, which evaluate changes between time periods, seven additional ques- tions on the after-implementation survey allowed participants to self- compare their perceptions before and after the implementation data collection point. Because this study was conducted in a new hospital, 6 complete months of data for medica-


Before (n=25)

Mean (SD)

After (n=20)

Mean (SD) p Value Effect Size

17. I have to keep stashes of medications to be sure I have medications I need when I need them.

3.09 (2.11) 3.28 (2.24) 0.78 0.002

18. When I see a message that acknowledges and accepts a known drug/drug interaction, I believe it is appropriate to give the medication.

2.92 (1.93) 2.67 (1.82) 0.67 0.004

19. The current system helps me to be time efficient at medication administration.

2.25 (1.29) 2.15 (0.93) 0.77 0.002

20. The current medication administration system helps keep the number of distractions I encounter low.

2.21 (1.22) 2.05 (0.89) 0.63 0.01

21. The current medication administration system allows simple and hygienic storage of medication.

2.29 (1.16) 1.85 (0.93) 0.18 0.04

TABLE 4. (continued) MAS-NAS Survey Results

TABLE 5. Responses to Additional Questions: Comparison of Nurse Perceptions

Before and After Cabinet Installation (N=17)

Question Mean (SD)*

It is easier to do all the checking steps needed during medication administration process.

1.84 (0.83)

This is a safer system for patients. 1.74 (0.73)

With the new system, it is easier to access information I need to administer medications.

1.95 (1.22)

I am more satisfied with this new medication administration system than with the previous one.

1.67 (0.84)

I have more time to spend with patients. 1.94 (0.87)

Medication cabinets have made the medication administration process more efficient for me.

2.00 (1.25)

Medications are more readily available when I need them for patients.

1.89 (1.24)

*On a 6-point Likert scale (1 Strongly Agree and 6 Strongly Disagree)

Source: Hurley et al., 2006. Reprinted with permission.

March-April 2014 • Vol. 23/No. 2 83

Instructions For Continuing Nursing

Education Contact Hours Evaluating the Impact of Medication Cabinets in

Patients’ Rooms on a Medical- Surgical Telemetry Unit

Deadline for Submission: April 30, 2016

MSN J1404

To Obtain CNE Contact Hours 1. For those wishing to obtain CNE con-

tact hours, you must read the article and complete the evaluation through AMSN’s Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to

2. Evaluations must be completed online by April 30, 2016. Upon completion of the evaluation, a certificate for 1.3 con- tact hour(s) may be printed.

Fees – Member: FREE Regular: $20

Objectives This continuing nursing educational (CNE) activity is designed for nurses and other health care professionals who are interest- ed in impact of medication cabinets in patients’ rooms. After studying the informa- tion presented in this article, the nurse will be able to: 1. Explain the use of medication cabinets

in patients’ rooms. 2. Describe the results of a study to meas-

ure nurses’ satisfaction with medication administration following the installation of medication cabinets in patients’ rooms.

3. Discuss implications for nursing practice based on the study results.

Note: The authors, editor, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity has been co-provided by AMSN and Anthony J. Jannetti, Inc.

Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of CA must retain this certificate for four years after the CNE activity is completed.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses’ Credentialing Center’s Commission on Accreditation.

This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director. Accreditation status does not imply endorsement by the provider or ANCC of any commercial product.

tion accuracy were not available before cabinet installation; a 1- month baseline was used and trends over 6 months after installation were compared. This limits the ability to make equal comparison between time periods.

Implications for Practice Findings support the premise that

nurse-initiated and implemented processes, such as use of medication cabinets, can increase nurses’ satisfac- tion with the medication administra- tion process through increased avail- ability of supplies and medications. Such processes also can affect patient safety. For example, nurses in this study perceived medication cabinets to be safer, easier to use, and more effi- cient for medication administration.

Findings from this study make several contributions to the current literature. First, findings related to impact on charge accuracy indicate the installation of medication cabi- nets inside patient rooms does not impact the accuracy of charges while increasing nurses’ satisfaction on the process of medication administra- tion. Second, use of medication cabi-

nets may not affect the incidence of medication errors. Third, use of med- ication cabinets allows nurses to spend more time with their patients, in turn increasing patient safety and supporting goals of a patient- and family-centered institution. In sum- mary, results suggest a nurse-driven innovation such as medication cabi- nets inside patient rooms supports nurse workflow and enhances nurses’ ability to provide safe patient care.

Future Research Possible areas for further research

in medication administration include patients’ perception of the medica- tion administration process. Of par- ticular benefit could be research con- cerning the direct impact of medica- tion cabinet use on patient care, including safe handling and adminis- tration of medications. For example, placement of a medication for an entire shift in a medication cabinet may reduce distractions associated with use of a central room for medica- tion preparation.

continued on page 119

FIGURE 3. Charge Accuracy Before and After Medication Cabinet Installation








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M ed

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C ha

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A cc

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Months Before and After Installation of Cabinets

July 2012

June 2012

May 2012

April 2012

March 2012

February 2012

November 2011 (Pre)*

* Data were available only 1 month before installation. Cabinet installation period was December 2011 to February 2012.

March-April 2014 • Vol. 23/No. 2 119

Evaluating the Impact of Medication Cabinets continued from page 83

Conclusion The results of this study may be used in supporting

practice changes. This research provides information that may assist in the future development and implementa- tion of systems that will maximize the benefits rather than introduce more errors into the current medication administration system. When new innovations are being implemented, the integration of the change into practice must support the workflow of nurses and not hinder their ability to provide safe patient care.

REFERENCES Bates, D. (2007). Preventing medication errors: A summary. American

Journal of Health-System Pharmacy, 64(14), S3-S9. Hurley, A., Bane, A., Fotakis, S., Duffy, M.E., Sevigny, A., Poon, E.G., &

Gandhi, T.K. (2007). Nurses’ satisfaction with medication administra- tion point-of-care technology. The Journal of Nursing Administration, 37(7/8), 343-349.

Hurley, A., Lancaster, D., Hayes, J., Wilson-Chase, C., Bane, A., Griffin, M., … Gandhi, T.K. (2006). The medication administration system – Nurses assessment of satisfaction (MAS-NAS) scale. Journal of Nursing Scholarship, 38(3), 298-300.

Hull, T., Czirr, L., & Wilson, M. (2010). Impact of medication storage cab- inets on efficient delivery of medication and employee frustration. Journal of Nursing Care Quality, 25(4), 352-357.

Keohane, C., Bane, A., Featherstone, E., Hayes, J., Woolf, S., Hurley, … Poon, E. (2008). Quantifying nursing workflow in medication admin- istration. The Journal of Nursing Administration, 38(1), 19-26.

Mandrack, M., Cohen, M., Featherling, J., Gellner, L., Judd, K., Kienle, P.C., & Vaderveen, T. (2012). Nursing best practice using automated dispensing cabinets: Nurses’ key in improving medication safety. Advance Practice, 21(3), 134-144.

National Research Council. (2007). Hospital-based emergency care: At the breaking point. Washington, DC: The National Academies Press. Retrieved from

Popescu, A., Currey, J., & Botti, M. (2010). Multifactorial influences on and deviations from medication administration safety and quality in the acute medical surgical context. World Views on Evidence- Based Nursing, 8(1), 15-24.

Wulff, K., Cummings, G., Marck, P., & Yurtseven, O. (2011). Medication administration technologies and patient safety: A mixed-method sys- tematic review. Journal of Advanced Nursing, 67(10), 2080-2095.

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