Diverting A Nurse In The Preparation Of Medicines Increases The Risk Of Errors

Diverting A Nurse In The Preparation Of Medicines Increases The Risk Of Errors.
Distracting an airline airman during taxi, takeoff or deplaning could chief to a critical error. Apparently the same is true of nurses who prepare and administer medication to health centre patients. A new study shows that interrupting nurses while they're tending to patients' medication needs increases the chances of error.

As the sum of distractions increases, so do the number of errors and the endanger to patient safety. "We found that the more interruptions a nurse received while administering a drug to a determined patient, the greater the risk of a serious error occurring," said the study's lead author, Johanna I Westbrook, commander of the Health Informatics Research and Evaluation Unit at the University of Sydney in Australia.

For instance, four interruptions in the lecture of a single drug administration doubled the probability that the patient would experience a major mishap, according to the study, reported in the April 26 efflux of the Archives of Internal Medicine. Experts say the study is the first to show a clear association between interruptions and medication errors.

It "lends mighty evidence to identifying the contributing factors and circumstances that can bring to a medication error," said Carol Keohane, program director for the Center of Excellence for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston. "Patients and blood members don't agree that it's dangerous to patient safety to interrupt nurses while they're working," added Linda Flynn, secondary professor at the University of Maryland School of Nursing in Baltimore. "I have seen my own family tree members go out and interrupt the nurse when she's standing at a medication haul to ask for an extra towel or something else inappropriate".

Julie Kliger, who serves as program director of the Integrated Nurse Leadership Program at the University of California, San Francisco, said that administering medication has become so stereotypic that Dick involved - nurses, health-care workers, patients and families -- has become complacent. "We requirement to reframe this in a new light, which is, it's an important, deprecating function. 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 determined harm and it costs money".

About one-third of harmful medication errors happen during medication administration, studies show. Prior to this study, though, there was little if any statistics on what role interruptions might play.

For the study, the researchers observed 98 nurses preparing and administering 4271 medications to 720 patients at two Sydney teaching hospitals from September 2006 through March 2008. Using handheld computers, the observers recorded nursing procedures during medication administration, details of the medication administered and the total of interruptions experienced.

The computer software allowed text to be unruffled on multiple drugs and on multiple patients even as nurses moved between cure-all briefing and administration and among patients during a medication round. Errors were classified as either "procedural failures," such as fault to read the medication label, or "clinical errors," such as giving the wrong drug or wrong dose. Only one in five knock out administrations (19,8 percent) was completely error-free, the study found.

Interruptions occurred during more than half (53,1 percent) of all administrations, and each intrusion was associated with a 12,1 percent increase, on average, in procedural failures and a 12,7 percent gain in clinical errors. Most errors (79,3 percent) were minor, having paltry or no impact on patients, according to the study. However, 115 errors (2,7 percent) were considered outstanding errors, and all of them were clinical errors.

Failing to check a patient's empathy against his or her medication chart and administering medication at the wrong time were the most common procedural and clinical glitches, respectively, the deliberate over reported. In an accompanying editorial, Kliger described one potential remedy: A "protected hour" during which nurses would nave on medication administration without having to do such things as rob phone calls or answer pages.

The idea is based on the US Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits insignificant activities and conversations with the voyage crew during taxi, takeoff, landing and all flight operations below 10,000 feet, excuse when the safe operation of the aircraft is at stake. Likewise, in nursing, not all interruptions are bad as example. "If you are being given a upper and you do not know what it is for, or you are uncertain about it, you should interrupt and question the nurse".