From Our 2010 Archives

Interrupting a Nurse Makes Medication Errors More Likely

By Karen Pallarito
HealthDay Reporter

MONDAY, April 26 (HealthDay News) -- Distracting an airline pilot during taxi, takeoff or landing could lead to a critical error. Apparently the same is true of nurses who prepare and administer medication to hospital patients.

A new study shows that interrupting nurses while they're tending to patients' medication needs increases the chances of error. As the number of distractions increases, so do the number of errors and the risk to patient safety.

"We found that the more interruptions a nurse received while administering a drug to a specific patient, the greater the risk of a serious error occurring," said the study's lead author, Johanna I. Westbrook, director of the Health Informatics Research and Evaluation Unit at the University of Sydney in Australia.

For instance, four interruptions in the course of a single drug administration doubled the likelihood that the patient would experience a major mishap, according to the study, reported in the April 26 issue 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 important evidence to identifying the contributing factors and circumstances that can lead 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 family members don't understand that it's dangerous to patient safety to interrupt nurses while they're working," added Linda Flynn, associate professor at the University of Maryland School of Nursing in Baltimore. "I have seen my own family members go out and interrupt the nurse when she's standing at a medication cart 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 routine that everyone involved -- nurses, health-care workers, patients and families -- has become complacent.

"We need to reframe this in a new light, which is, it's an important, critical function," Kliger said. "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 patient harm and it costs money."

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

For the study, the researchers observed 98 nurses preparing and administering 4,271 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 number of interruptions experienced.

The computer software allowed data to be collected on multiple drugs and on multiple patients even as nurses moved between drug preparation and administration and among patients during a medication round.

Errors were classified as either "procedural failures," such as failing to read the medication label, or "clinical errors," such as giving the wrong drug or wrong dose.

Only one in five drug administrations (19.8%) was completely error-free, the study found.

Interruptions occurred during more than half (53.1%) of all administrations, and each interruption was associated with a 12.1% increase, on average, in procedural failures and a 12.7% increase in clinical errors.

Most errors (79.3%) were minor, having little or no impact on patients, according to the study. However, 115 errors (2.7%) were considered major errors, and all of them were clinical errors.

Failing to check 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 study reported.

In an accompanying editorial, Kliger described one potential remedy: A "protected hour" during which nurses would focus on medication administration without having to do such things as take phone calls or answer pages.

The idea, Kliger said, is based on the U.S. Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits non-essential activities and conversations with the flight crew during taxi, takeoff, landing 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.

"If you are being given a drug and you do not know what it is for, or you are uncertain about it, you should interrupt and question the nurse," she said.

Medical NewsCopyright © 2010 HealthDay. All rights reserved.

SOURCES: Johanna I. Westbrook, Ph.D., professor, health informatics, and director, Health Informatics Research and Evaluation Unit, University of Sydney, Australia; Carol Keohane, R.N., program director, Center of Excellence for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston; Linda Flynn, R.N., Ph.D., associate professor, University of Maryland School of Nursing, Baltimore; Julie Kliger, R.N., M.P.A., program director, Integrated Nurse Leadership Program, Center for the Health Professions, University of California, San Francisco; Aviation Safety Reporting System, NASA, Moffett Field, Calif.; April 26, 2010, Archives of Internal Medicine