Don't Interrupt the Nurse
The Federal Aviation Administration has established the “sterile cockpit” rule which prohibits non-essential activities while the pilot goes through a safety checklist and prepares the flight for taxi and takeoff.
The same may be needed for nurses.
A just published study in the Archives of Internal Medicine shows that interrupting nurses with phone calls and paperwork as they prepare medications and administer them increases the number of errors.
This is the first time a direct link has been shown between interruptions and medication errors.
"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.
In this study, researchers at two Sydney, Australia teaching hospitals observed 98 nurses as they prepared and administered 4,271 medications to 720 patients. The study period ran from September 2006 to March 2008. Observers recorded the medication, its preparation and the number of interruptions on multiple rounds.
Only one in five or 20% was completely error-free.
Interruptions occurred more than half of the time (53.1%), the study finds, which led to a procedural failure rate of 85% and a clinical failure rate of almost 40%. Errors were interpreted as failing to read the medication label (procedural failure) or giving the wrong does or drug (clinical error).
Fortunately almost 80% of the errors were minor and had little impact on patients, but 2.7% were major clinical errors or mistake in drug or dosage. The study finds that nurses forgot to check patient charts or gave the meds at the wrong time.
Every interruption was associated with a 12.1 % increase in procedural failures and a 12.7% increase in clinical errors, reports HealthDay.
It is always advisable to interrupt a nurse to double check if the medication is correct.
Medication errors rank high as a cause of the estimated 98,000 to 200,000 fatal medical errors performed every year and may occur at a rate of one per patient per day. #