Interruptions and Medication Errors Part I

Internal Medicine Services, Baylor University Medical Center, Dallas, Texas, USA.
Clinical nurse specialist CNS (Impact Factor: 0.99). 08/2012; 24(6):281-5. DOI: 10.1097/NUR.0b013e3181faf78b
Source: PubMed
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    ABSTRACT: In the fast-paced environment of a cardiac and thoracic surgery telemetry unit, nurses are interrupted hundreds of times per day. These interruptions can have a detrimental effect on patient safety during medication administration. This article describes a bundle of safety interventions that reduced the average number of interruptions during medication administration by 2.11 interruptions per encounter and decreased reported medication errors by a total of 28 incidents over a 3-month period.
    Full-text · Article · Oct 2012 · Journal of nursing care quality
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    ABSTRACT: The well-established Institute of Medicine report entitled To Err is Human: Building a Safer Health System highlighted the importance of preventative errors in medicine, suggesting interruptions are a contributing factor. Patient safety organisations, such as The Joint Commission, acknowledge that interruptions contribute to preventable medical errors. The aim of this research is to examine the most frequently observed interruptions experienced by nurses administering medications and evaluate an intervention designed to reduce those interruptions. The primary intervention consisted of a White Vest worn during administration stating: 'Please do not interrupt while passing medications'. A quasi-experimental design was employed. Nurses were observed for 2 weeks during routine administration of morning medications. The vest was then introduced and worn during administration for 2 weeks for post-intervention data collection. The hospital unit, date, time, duration, and description of the interruption were recorded. Data collection was conducted in four hospital units sequentially. A content analysis revealed the most frequently observed interruptions were comments/questions by hospital staff, phone calls, and seeking supplies. As hypothesised, the overall number of interruptions during medication administration (MA) declined after implementation of the intervention. This study illustrates implications and policy changes with regards to nursing practices and MA. © The Author(s) 2013 Reprints and permissions:
    No preview · Article · Apr 2013

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