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 lead during taxi, takeoff or arrival could first to a critical error. Apparently the same is true of nurses who prepare and administer medication to medical centre patients going here. A new study shows that interrupting nurses while they're tending to patients' medication needs increases the chances of error.

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

For instance, four interruptions in the order of a single drug administration doubled the good chance that the patient would experience a major mishap, according to the study, reported in the April 26 problem 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 material evidence to identifying the contributing factors and circumstances that can leash 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 strain members don't take it that it's dangerous to patient safety to interrupt nurses while they're working," added Linda Flynn, collaborator professor at the University of Maryland School of Nursing in Baltimore. "I have seen my own brood members go out and interrupt the nurse when she's standing at a medication barrow 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 monotonous that person involved - nurses, health-care workers, patients and families -- has become complacent. "We penury to reframe this in a new light, which is, it's an important, perilous function," Kliger said. "We need to give it the respect that it is due because it is high volume, high peril and, if we don't do it right, there's patient harm and it costs money".

About one-third of injurious medication errors occur during medication administration, studies show. Prior to this study, though, there was mean if any data 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 million of interruptions experienced.

The computer software allowed matter to be controlled on multiple drugs and on multiple patients even as nurses moved between treatment organization and administration and among patients during a medication round. Errors were classified as either "procedural failures," such as wanting to read the medication label, or "clinical errors," such as giving the wrong drug or odd dose. Only one in five drug administrations (19,8 percent) was completely error-free, the boning up found.

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

Failing to control a patient's identification 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 latent remedy: A "protected hour" during which nurses would focus on medication administration without having to do such things as weather phone calls or answer pages.

The idea, Kliger said, is based on the US Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits uncalled-for activities and conversations with the swarm crew during taxi, takeoff, splashdown and all flight operations below 10,000 feet, except when the safe operation of the aircraft is at stake. Likewise, in nursing, not all interruptions are bad, Westbrook added sildenafil box. "If you are being given a opiate and you do not be familiar with what it is for, or you are uncertain about it, you should interrupt and question the nurse," she said.