Interrupting a nurse just once in the process of preparing and administering medication was associated in a large-scale study with a 12% increase in procedural errors (such as a breach in sterile technique) and a 13% increase in clinical errors (such as wrong timing or wrong dose). The severity of errors was also found to increase with interruption frequency.
In the study, published in Archives of Internal Medicine earlier this year (2010;170(8):683–690), researchers, led by Joanna I. Westbrook, PhD, of the University of Sydney, observed nurses preparing and administering medications at two urban teaching hospitals over the course of 18 months.
The study included 4,271 medication doses given to 720 patients over a total of 505 hours.
The most frequent procedural error was failing to check the patient's ID against the medication administration record before drug administration.
Wrong timing was the most frequent clinical error, but only about 4% of these errors were serious.
The second most frequent clinical error was wrong IV administration rate, and 36% of these errors were serious.
Longer experience did not reduce the risk of errors—in fact, part-time and less experienced nurses were found to have lower rates of procedural failures.
Dr. Westbrook and her colleagues speculated that full-time, experienced nurses are more likely to believe they can visually identify their patients and safely bypass the ID protocol.
Among the strategies the researchers suggested for reducing nurse interruptions during drug preparation and administration were to establish a protected hour when nurses focus on drug administration without taking phone calls, answering pages, or performing other nursing tasks.
Another strategy being tested in some hospitals is having nurses wear specific labeled “interruption vests” that say something like “Do Not Interrupt—Medication Round in Progress.”
The team also urged more research into prevention strategies, and said that the data confirm conclusions from a review published recently by the U.S. Agency for Healthcare Research and Quality that the rate of medication administration errors is “truly staggering.”
Adapted from Nursing 2010, July 2010