Medication Errors: Distraction and Interruptions
A Sample Answer For the Assignment: Medication Errors: Distraction and Interruptions
Title: Medication Errors: Distraction and Interruptions
Medication Errors: Distraction and Interruptions
EVIDENCE BASED CARE SHEET
Medication Errors: Distraction and Interruptions What We Know › The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP; a United States-based council consisting of 27 healthcare organizations, including the American Hospital Association, the American Nurses Association, the Food and Drug Administration, and The Joint Commission) defines a medication error as “any preventable event that can cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events can be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”(7) • Medication errors are common occurrences in the healthcare setting, causing injury to over 1.5 million patients and accounting for 7,000 preventable deaths in the U.S. each year.(5) Other potential consequences of medication errors are staff distress, increased health care costs, increased length of hospital stay, and legal ramifications(1,2,8,10) • Safe administration of medications is one of The Joint Commission’s Medication ICD-9 995.20 ICD-10 T50.901A Authors Arsi L. Karakashian, RN, BSN Armenian American Medical Society of California Tanja Schub, BS Cinahl Information Systems, Glendale, CA Reviewers Sara Richards, MSN, RN Cinahl Information Systems, Glendale, CA Alysia Gilreath-Osoff, RN, MSN Cinahl Information Systems, Glendale, CA Nursing Executive Practice Council Glendale Adventist Medical Center, Glendale, CA Editor Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems, Glendale, CA Management standards(4) › Medication errors can occur at any point during medication use—including prescribing, transcribing, dispensing, administering, and monitoring—but a disproportionately large number of errors occur during medication administration, one of the most frequent activities performed by nurses(1,3,8) • Medication administration, a risky procedure requiring mental focus, is one of the most frequently interrupted nursing care activities; distractions (i.e., events that draw or direct a healthcare provider’s attention somewhere else) and interruptions (i.e., events that stop the healthcare provider’s current action) have been identified as important contributors to medication errors. Rates of medication errors are higher in environments with higher levels of distraction and interruption(2,3,8,10,14) – Interruptions are common during the medication administration process(6,13) – Researchers observed 43 nurses on 56 drug rounds and found that they experienced a median of 5.5 interruptions and 9.6 distractions per hour(6) – In a study in which 227 nurses were observed administering 4,781 medications, investigators reported that nurses experienced 57 interruptions per 100 administrations; 87.9% of the interruptions were unrelated to the medication administration task the nurse was performing(13) –Other nurses and staff members are the most common sources of interruptions during medication administration(12) – Other sources of interruption include patients and patient family members, telephone calls, and alarms (e.g., from ventilators, telemetry monitors)(2,3) –Potential distractions in the hospital setting include personal conversations, background noise, a hectic work day, and a crowded work space(2,3,9) December 14, 2018 Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2021, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 • Distractions and interruptions can lead to medication errors by creating mistakes in any of the six “rights” of medication administration—the right patient, the right medication, the right dose, the right time, the right route, and the right documentation(1) –In a study conducted in five medical-surgical units at two acute care hospitals in the U.S., interruptions occurred during 39% of medication tasks. Nurses most commonly responded to interruptions by halting the medication task deal with the reason for the interruption (51%) or multitasking (40%); they delayed attending to the interruption until after the medication task was complete in just 13% of cases(11) › Some interventions to reduce medication errors related to distraction and interruptions come from other high-risk fields, such as the airline and nuclear power industries(1,2,3,10) • The aviation industry’s “sterile cockpit rule” mandates that aircraft personnel avoid engaging in nonessential tasks and communications during high-risk periods (e.g., takeoff and landing); when applied to a healthcare setting, the “sterile cockpit rule” might dictate that conversations be focused on delivery of medication, that irrelevant phone calls or pages be ignored, and that phones in or near the medication rooms be removed(1,2,3) › Other interventions that aim to limit or eliminate distractions and interruptions to reduce rates of medication errors include • designating “no interruption zones” around medication preparation areas(1,3) –In a study in which this concept was implemented in an ICU environment, the rate of interruptions during medication preparation decreased by 41% over a 3-week period(1) • posting visible signage (e.g., Do Not Disturb signs) to promote a quiet environment and warn people that the nurse is not to be interrupted during medication preparation and administration(2,3,8) –Nurse administrators on a 35-bed pulmonary-medical unit in a large academic medical center began posting two octagonal reds signs that read “Stop/Medication Administration in Progress/Please Do Not Disturb the Nurse” on each medication cart. Two months after implementing this strategy, just 31% of nurses reported a reduction in interruptions, citing failure of staff members to respect the signs as the most common problem(2) • having nurses wear “non-interruption” attire to designate that they are engaged in medication preparation or administration and should not be disturbed(1,3) –In a pilot study in which nurses at Kaiser Hospital in California wore a yellow sash during medication preparation and administration, the rate of staff interruptions decreased by 50%(3) • allocating time in the nurses’ schedule specifically for medication-related duties(8) –The Medication Pass Time Out program was designed to reduce medication errors at Stanford Hospital & Clinics by designating 1 hour early in a nursing shift for uninterrupted preparation and administration of medications. This led to an increase in the percent of medication doses administered without interruption from 81% to 99% and an increase in medication doses administered without errors from 98% to 100%(8) › Bundled interventions can reduce the rate of interruptions during medication administration, but might not be embraced by nurses(10,13) • When nurse administrators implemented a five-partintervention—including the use of sashes, signs, and a checklist protocol, along with designation of a quiet zone marked off by floor tape and staff member education—at a 600-bed, acute care hospital, the rate of nurse interruptions during medication administration fell by 84%(10) • The implementation of a bundled intervention that included wearing a vest during medication preparation and administration, using strategies to divert interruptions, educating patients and clinicians about the need to avoid interrupting nurses unnecessarily, and posting reminders (e.g., posters) to avoid interrupting nurses during medication rounds resulted in a statistically significant reduction of 15 interruptions per 100 medication administrations compared to the rate observed on a control ward. However, nurses found use of the vests to be time consuming and uncomfortable; just 48% of surveyed nurses reported that they were in favor of the bundle becoming hospital policy(13) What We Can Do › Learn about the contribution of distraction and interruptions in causing medication errors. Share this information with your colleagues › Focus on the six “rights” of medication administration, while making every effort to ignore potential disruptors, to reduce your risk of making medication errors › Collaborate with your colleagues, supervisor, and continuing education faculty to identify unit-specific and facility-wide sources of distraction and interruptions that could lead to medication errors; develop and implement plans to minimize or eliminate these potential disturbances based on your findings Coding Matrix References are rated using the following codes, listed in order of strength: M Published meta-analysis RV Published review of the literature SR Published systematic or integrative literature review RU Published research utilization report X Practice exemplars, stories, opinions RCT Published research (randomized controlled trial) QI Published quality improvement report GI General or background information/texts/reports L Legislation R Published research (not randomized controlled trial) PP Policies, procedures, protocols C Case histories, case studies PGR Published government report U Unpublished research, reviews, poster presentations or other such materials G Published guidelines PFR Published funded report CP Conference proceedings, abstracts, presentation References 1. Anthony, K., Wiencek, C., Bauer, C., Daly, B., & Anthony, M. K. (2010). No interruptions please: Impact of a no interruption zone on medication safety in intensive care units. Critical Care Nurse, 30(3), 21-29. doi:10.4037/ccn2010473 (R) 2. Federwisch, M., Ramos, H., & Adams, S. C. (2014). The sterile cockpit: An effective approach to reducing medication errors? American Journal of Nursing, 114(2), 47-55. doi:10.1097/01.NAJ.0000443777.80999.5c (R) 3. Flanders, S., & Clark, A. P. (2010). Interruptions and medication errors: Part I. Clinical Nurse Specialist, 24(6), 281-285. doi:10.1097/NUR.0b013e3181faf78b (RV) 4. The Joint Commission. (2018). Comprehensive accreditation manual: CAMH for hospitals. Oakbrook Terrace, IL: The Joint Commission. (G) 5. Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139. doi:10.1136/bmj.i2139 (GI) 6. McLeod, M., Barber, N., & Franklin, B. D. (2015). Facilitators and barriers to safe medication administration to hospital inpatients: A mixed methods study of nurses’ medication administration processes and systems (the MAPS Study). PLoS ONE, 10(6), e0128958. doi:10.1371/journal.pone.0128958 (R) 7. National Coordinating Council for Medication Error Reporting and Prevention. (n.d.). About medication errors: What is a medication error? Retrieved December 10, 2018, from http://www.nccmerp.org/about-medication-errors (GI) 8. Nguyen, E. E., Connolly, P. M., & Wong, V. (2010). Medication safety initiative in reducing medication errors. Journal of Nursing Care Quality, 25(3), 224-230. doi:10.1097/ NCQ.0b013e3181ce3ae4 (R) 9. Odberg, K. R., Hansen, B. S., Aase, K., & Wangensteen, S. (2018). Medication administration and interruptions in nursing homes: A qualitative observational study. Journal of Clinical Nursing, 27(5-6), 1113-1124. doi:10.1111/jocn.14138 (R) 10. Pape, T. M. (2013). The effect of a five-part intervention to decrease omitted medications. Nursing Forum, 48(3), 211-222. doi:10.1111/nuf.12025 (R) 11. Reed, C. C., Minnick, A. F., & Dietrich, M. S. (2018). Nurses’ responses to interruptions during medication tasks: A time and motion study. International Journal of Nursing Studies, 82, 113-120. doi:10.1016/j.ijnurstu.2018.03.017 (R) 12. Schoers, G. (2018). Characteristics of interruptions during medication administration: An integrative review of direct observational studies. Journal of Clinical Nursing, 27(19-20), 3462-3471. doi:10.1111/jocn.14587 (SR) 13. Westbrook, J. L., Li, L., Hooper, T. D., Raban, M. Z., Middleton, S., & Lehbom, E. C. (2017). Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: A cluster randomised controlled feasibility study. BMJ Quality & Safety, 26(9), 734-742. doi:10.1136/bmjqs-2016-006123 (RCT) 14. World Health Organization. (2016). Medication errors: Technical series on safer primary care. Retrieved December 10, 2018, from http://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;jsessionid=5C73348306645D986804B3D2C38DB32D?sequence=1 (G)
