Table 2. Examples of system configurations and features, and their potential positive and negative effects on medication safety, workflow, interruptions and distractions.

Potential positive aspects of system configurations and features	Potential negative aspects of system configurations and features
Facilitating medication preparation next to drug chart/EPMA system (1) A desktop computer was near the stock cupboard for oral medicines, thus allowing nursing staff to check the EMAR while preparing medicines that may not be available from the drug trolley; (2) The patient bedside medication locker was a removable drawer which could be moved to an alternative area while preparing medicines (for example, if there was limited space at the locker to place the drug chart or mobile EPMA device, or if more than one drug was required from the bedside medication locker).	Practicalities of the drug chart/EPMA system (1)Drug administration codes for ‘patient refused’ and ‘patient did not require’ were used interchangeably Reported unreliability of tablet computer devices and font size too small on laptop led to nurses reporting a preference for using the desktop computer on some drug rounds. This meant that the EMAR was sometimes not used at the patient’s bedside or at the drug preparation location (e.g. treatment room); (2) Password and training required to use EPMA system, therefore EPMA could not be used by agency staff. Instead, regular nursing staff printed out medication administration records for agency staff and transcribed medication administration documentation on to the EPMA system after each drug round (signature on EPMA system was of the transcribing nurse).
Facilitating medication retrieval during drug round (1) Some patients kept their bedside medications together in a box which seemed to make it easier for nursing staff to find medications not stored in the bedside medication locker, for example, creams and inhalers; (2) Medications in the drug trolley were arranged such that the front (rather than the side) of most packs were facing the nurse to aid identification: (3) Drug trolley was kept in the treatment room and was often replenished immediately prior to and/or after the drug round; (4) Drug trolley was kept in the treatment room which also had a fridge; fridge items were placed in the drug trolley prior to starting the drug round.	Travel (1)Not all the medications or equipment (drug charts, keys, paper/plastic medicine cups) required during the drug rounds were available at the patient’s bedside. Some may be temporarily placed elsewhere but others such as infusion pump equipment were located in a separate room some distance away from the patient’s bedside and potentially increased travel for nurses; (2) The day room was located some distance away from the patient bed areas which was a particular problem on one ward as some patients were mobile and were often in the day room during drug rounds; thus potentially increased travel and opportunities for interruptions.
Reducing interruptions and distractions (1) Ward staff developed a standard form for documenting medication-related tasks that required follow-up after the drug round; (2) Ward staff placed a ‘ward screen’ at the entrance of a bay in which patients were being washed, this discouraged interruptions to anyone inside the bay including interruptions to nurses who were carrying out the drug round at the same time; (3) Nurse checked EPMA at the nurse station prior to starting lunchtime drug round for doses that were due. Nurse expected very few doses and did not use drug trolley on the drug round but prepared medications at the nurse station from the stock cupboard.	Medication security and accessibility (1) A few medicines (for example, nebules and pre-filled syringes) were sometimes kept on the shelf at the bottom of the drug trolley in addition to inside the drug trolley which was accessible to passers-by; (2) Some frequently used IV drugs (e.g., paracetamol [acetaminophen] and metronidazole) were stored on high shelves which made them difficult to retrieve; (3) Some patient bedside medication lockers were positioned so that the locker opened towards the bed to facilitate patient self-administration (rather than towards the nurse opening it) which made it more difficult for the nurse to access the contents when the patient was not self-medicating; (4) Nurses had to stoop to open patient bedside medication lockers.

Abbreviations: EMAR, electronic medication administration record; EPMA system, electronic prescribing and medication administration system; HCA, health care assistant; HCP, health care professional; IV, intravenous.