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July 2010, Volume 40 Number 7 , p 19 - 21



In a major study, researchers observed nurses preparing and administering medications at two urban teaching hospitals over 18 months. The study included 4,271 medication doses given to 720 patients over 505 hours. The researchers found that interrupting a nurse just once in the process was associated with a 12% increase in procedural errors (such as a breach in sterile technique) and a 13% increase in clinical errors (such as wrong timing or wrong dose). In addition, the severity of errors increased with interruption frequency.The most frequent procedural error was failing to check the patient's ID against the medication administration record before drug administration. Wrong timing was the most frequent clinical error, but only about 4% of these errors were serious. The second most frequent clinical error was wrong I.V. administration rate; 36% of these errors were serious.Nurse experience didn't reduce the risk of errors. In fact, researchers found that part-time and less-experienced nurses had lower rates of procedural failures. They speculate that full-time, experienced nurses are more likely to believe they can visually identify their patients and safely bypass the ID protocol.Researchers discuss various strategies to reduce nurse interruptions during drug preparation and administration, such as establishing a protected hour when nurses focus on drug administration without taking phone calls, answering pages, or performing other nursing tasks. Another strategy being tested in some hospitals is having nurses wear "interruption vests" that state Do not interrupt, medication round in progress.Calling for more research into prevention strategies, researchers conclude that "our data confirm conclusions from a review published recently by the U.S. Agency for Healthcare Research and Quality that the rate of medication administration errors is 'truly staggering.'"Source: Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions

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