Redesigning From Work-as-Imagined to Work-as-Done: A Systems Safety Approach to Bedside Medication Storage

This quality improvement study aimed to address challenges in medication storage and accessibility in an acute pediatric care setting. By examining current processes, improvement opportunities were identified to enhance medication availability and reduce errors by introducing new locked medication storage boxes for multiuse, patient-specific medications.

This quality improvement study was conducted in a 38-bed medical-surgical unit at a large Midwestern pediatric hospital. The study consisted of 3 phases: preintervention, simulation, and postintervention. Preintervention included near miss frequency counts, bedside medication audits, time observation audits, and a knowledge survey. The simulation phase involved in-situ simulations over 2 shifts with ten nurses (n=10), measuring success rates, task completion times, workload, and task difficulty and confidence ratings. Postintervention activities repeated the initial measures collected during the preintervention phase.

Participants showed a higher task success rate (94.6%) for the work-as-imagined procedure compared with a work-as-done (60%) and intervention (89%) processes. Overall, the intervention process decreased perceived workload according to the unweighted NASA-Task Load Index (NASA-TLX) scores and decreased task time compared with the work-as-imagined storage process. Confidence in task completion was highest for work-as-imagined, with a slight decrease in difficulty for the intervention or work-as-done.

This study underscores the importance of identifying and addressing gaps between organizational policies or standard operating procedures and actual practices while engaging frontline staff. The implementation of new medication lockboxes significantly improved the medication storage process, demonstrating the effectiveness of quality improvements methods in enhancing both safety and efficiency. These findings highlight the value of a collaborative, systems-based approach in driving meaningful improvements in health care settings, ultimately contributing to better patient outcomes and operational efficiency.