Tuesday, May 4, 2010

One Quick Patient Safety Tip: Interupting Nurses Increases Chances of Medication Errors

This news should come as no surprise to any one, but perhaps the magnitude of the numbers will. A recent study published in the Archives of Internal Medicine shows a clear association between nurses being interrupted during medication administration and subsequent medication errors. As the number of distractions increase, so do the number of errors.

The study observed 98 hospital nurses during 4,271 medication administrations and found that interruptions occurred in 53% of them. That number seems very high to me particularly when you consider that only 11% of the interruptions were necessary. There are issues like monitor alarms and other critical events that must be dealt with regardless of what the nurse is doing. But the other interruptions just represent a wonderful opportunity for process improvement that will have a direct impact on patient safety.

Let's look at the consequences of these interruptions. Of those nurses who were interrupted, 74% had at least one procedural error and 25% had at least one clinical error. These rates shot up to 85% and 39% respectively when nurses were interrupted at least three times. If a nurse was interrupted four times, the patient was twice as likely to experience a medication error versus and uninterrupted nurse.

When you consider how prevalent medication errors are and the one third of them occur during administration by the nurse, it seems like an obvious area to address. This is the first study I am aware of that links medication errors and nurse interruptions. There are many critical tasks where we make sure the individual involved is not distracted; a pilot during take off or a surgeon in the OR. Let's provide our nurses with a Protected hour for medication administration.

More on this later

Mark Brodeur

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