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A risky distraction

Study finds interrupting nurses while they are tending to patients’ medication needs increases the chances of error.

Nurses could soon be seen walking the wards wearing “do not disturb” signs to cut down on the number of interruptions while trying to give out medications to patients.

That is one strategy suggested for hospitals to implement following an Australian study that found interrupting nurses while they are tending to patients’ medication needs increased the chances of error. As the number of distractions increases, so does the risk to patient safety.

Interruptions have long been blamed for medical errors. But this research, published last month in the Archives of Internal Medicine, is the first to directly examine the link between distractions and mistakes in nursing care.

It found that only 19.8 per cent of administrations were free of error, which included not checking the patient’s identification through to administering the wrong drug dose.

The research team, headed by University of Sydney’s Professor Johanna Westbrook, studied 98 nurses in six wards of two major Sydney teaching hospitals. Observed over a period of about two years, the nurses prepared and administered 4271 medications to 720 patients.

Interruptions were noted and two types of errors were tracked: procedural failures, including failure to read labels, check patient identification or record administration on medication chart; and clinical errors, including wrong drug use, dose, formulation or strength.

At least one procedural failure occurred in 74.4 percent of administrations and one clinical failure in 25 per cent. Nurses were interrupted at least once in more than half of all drug administrations.

“Experimental studies suggest that interruptions produce negative impacts on memory by requiring individuals to switch attention from one task to another,” Westbrook said.

“Returning to a disrupted task requires completion of the interrupting task and then regaining the context of the original task.”

For each interruption there was a 12.1 per cent increase in procedural failures and a 12.7 per cent increase in clinical errors.

Failing to check the patient’s identification against their medication chart was the most common procedural error, the study said. In only 41.3 per cent of administrations was the identification procedure undertaken.

Surprisingly, it was the more experienced nurses who were more likely to make this mistake
“Full-time, experienced nurses may believe that they can easily visibly identify patients and therefore a formal identification process is not necessary. However, recognising a patient does not ensure you have the correct medication chart,” Westbrook said.

Giving a drug at the wrong time was the most frequent clinical error with 4.1 per cent rated as being of major severity. Setting intravenous drips at the wrong dosage rate was the second most common clinical error, with 35.7 per cent of these rated as being of major severity.

Errors became more severe as the number of interruptions increased, said Westbrook.

“Without interruption, the estimated risk of major error was 2.3 per cent. With four interruptions the risk doubled to 4.7 per cent.”

But, who should be held accountable for the high error rates?

The entire professional medical, nursing and administrative team, according to Julie Kliger, who wrote an accompanying, invited commentary.

“The frequency of interruptions during medication administration suggests a lack of understanding of the importance of this process and of the deleterious effects of interruptions on patient safety,” wrote Kliger, who is the program director for the Integrated Nurse Leadership Program at the University of California.

“More significantly, it alerts us to a widespread lack of respect for the medication administration process. We need to give it the respect that it is due because it is high volume, high risk and, if we don’t do it right, there’s patient harm and it costs money.”

While not all interruptions are bad and are central to providing safe care, Westbrook said there was a need to better understand the reasons for such high interruption rates.

There is also a need to develop and implement strategies to improve communication practices and to reduce unnecessary interruptions, she said.

The use of interruption vests to be worn by nurses on medication rounds, which have “Do no interrupt” printed on them is one strategy that is being used in overseas hospitals with success.

New information technologies, such as electronic medication management systems, show promise in reducing errors, however, they are also a potential new source of interruption, the study said.

Previous studies have found that that when such a system is used, nurses were required to interrupt others is order to use the system effectively. “But, it is also possible that, if well designed, system features could reduce some of the negative effects of interruptions and support memory recall of interrupted tasks.”

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