In response to: Human factors design: Safety and medication administration
We read with interest the quality improvement project describing a light-up lanyard as a visual cue to reduce interruptions during medication double checks. While we commend nurse-led innovation and commitment to bedside safety, we caution drawing conclusions on an improvement project’s success based on a very small sample size. Further, a multicenter cluster randomized controlled trial demonstrated no statistically significant reduction in medication errors nor interruptions when similar “do not interrupt” vests were used.1
High alert medications require safeguards across the entire medication use process, from prescribing through monitoring, not concentrated at the moment of administration. 2,3 Medication errors are consistently reported to our organization despite documented double checks, which signals system design problems, not vigilance problems. Human factors engineering advises taking a comprehensive systems approach, rather than introducing a simple behavioral intervention. 4
This lanyard intervention adds complexity at the last point in the medication use process, rather than redesigning upstream to prevent the error from reaching the bedside. More productive questions include: Does the medication arrive at bedside ready to administer, eliminating manipulation by the nurse? Do clinical decision support, technology, labels, and infusion products make it easy to do the right thing and difficult to do the wrong thing? Can electronic health records communicate directly with infusion pumps to reduce wrong-rate or wrong-weight entry?
When employed judiciously, conducted properly, and bundled with other strategies, manual independent double checks can be part of a valuable defense to prevent potentially harmful errors from reaching patients. Moving forward requires redesigning the system, not asking nurses to absorb more burden at the point of care.
Jana OHara, MSN, RN, CPHFH, CPHQ, CPPS – Director of Consulting and Education, Institute for Safe Medication Practices, an ECRI Company
Rita Jew, PharmD, MBA, BCPPS, FASHP – President, Institute for Safe Medication Practices, an ECRI Company
Polly Tremoulet, PhD – Director of Human Factors Engineering, ECRI
References
1 Berdot S, Vilfaillot A, Bezie Y, Perrin G, Berge M et al. Effectiveness of a “do not interrupt” vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. BMC Nursing 2021;20:153. doi.org/10.1186/s12912-021-00671-7.
2 Institute for Safe Medication Practices (ISMP). ISMP List of High-Alert Medications in Acute Care Settings. ISMP; 2024. https://www.ismp.org/recommendations/high-alert-medications-acute-list
3 Institute for Safe Medication Practices (ISMP). ISMP Targeted Medication Safety Best Practices for Hospitals. ISMP; 2026. https://home.ecri.org/blogs/ismp-resources/targeted-medication-safety-best-practices-for-hospitals
4 Chadwick LM, O’Dea A. Reclaiming the systems identity of human factors and ergonomics in healthcare. Human Factors in Healthcare. 2026;9:100130. doi:10.1016/j.hfh.2026.100130
Author Response
On behalf of our project team, we thank Ms. O’Hara, Dr. Jew, and Dr. Tremoulet for their thoughtful engagement with our work and for affirming the value of nurse-led innovation in patient safety.
This project was a Lean Six Sigma Green Belt initiative: a single-site, rapid-cycle test of change. Our aim was to investigate a locally identified concern and generate learning to inform future improvement, not to establish generalizable evidence. As noted in the original article, the small sample (n=12), the 26% reduction in independent double check completion time, and 70% reduction in interruptions were presented as encouraging, preliminary findings. References to scaling this approach describe a direction for future testing, not a demonstrated outcome of the pilot.
We agree that high alert medications require safeguards across the full medication-use process and that upstream redesign, including ready-to-administer preparations, robust decision support, and electronic health record-infusion pump interoperability, offers durable protection against harm.
Upstream and point-of-care improvement can also work together as part of a broader safety strategy. Complex challenges rarely yield to a single solution, and small tests of change, while no substitute for systems engineering, can surface local vulnerabilities and inform where larger efforts are warranted. Our intervention emerged from process mapping, cause-and-effect analysis, direct observation, and frontline nurse input, which identified interruption as a recurring factor in the double-check process.
Such projects also build capability among the nurses who lead them, strengthening capacity for the larger systems work. Small-scale improvement warrants humility about what it can demonstrate, and even modest interventions can contribute meaningfully when evaluated within their intended scope.
We appreciate ISMP and ECRI’s continued leadership in medication safety and welcome ongoing dialogue on advancing safer medication systems together.
– Julie Murphy, PhD, MBA, RN, CPHQ; Dorothy Miller, MPH; Kathryn Gustafson, BSN, RN; Alexandra Paulson, MSN, RN, CPN; Jennifer Treseler, MSN, RN, CPN, CPHQ; Kate Becla, MSN, RN, CCRN; Kate Donovan, PhD, MBA, MS
