Fig 3. Spaghetti diagram showing non-linear travel by one nurse (bank staff) during a morning drug round at site A (map of ward not drawn to scale).

Nurse started the drug round by wheeling the drug trolley from opposite the nurse station to side room D. Nurse went to the treatment room 11 times during the drug round: to look for medicines in the stock cupboard (2 times),to prepare medications for intravenous administration (5), to look for the drug chart (1) and to access the medicines fridge (3). During the drug round, the nurse also travelled to locations other than between the drug trolley and patients’ bedside: another drug trolley to look for medicines (4 times), nurse station to look for drug chart (1), nurse station to look for keys (2), kitchen to retrieve nutritional supplement (1), to another nurse to provide handover of patients (2), and to the ward next door to look for medicine (1). S01, site code; DR006, drug round code; N06, nurse code. Letters refer to ward bay areas.