Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project

Magnitude and associated factors of medication administration error among nurses working in Amhara Region Referral Hospitals, Northwest Ethiopia

Introduction

Medication administration errors (MAEs) are common health problems that threaten patient safety and raise mortality rates, duration of hospital stay, and cost of services. It also influences healthcare professionals performing the procedure and healthcare organizations. Its prevalence in Ethiopia is high ranging from 51.8% to 90.8%.

Objective

This study aimed to assess the magnitude and associated factors of MAE among nurses at Northwest Amhara Region Referral Hospitals.

Methods

An institution-based cross-sectional study was conducted from February to March 2019. A simple random sampling technique was employed to select 348 nurses. Structured pretested self-administered questionnaires and an observational checklist were used to collect data. The data were entered in Epi-info version 7, analyzed using SPSS version 20 (SPSS Inc., Chicago, IL), and presented in tables and graphs. Bivariate and multivariable logistic regressions were computed to identify the factors associated with MAEs. p Values <.05 and adjusted odds ratios were used to declare the significance and strength of the association.

Results

One hundred and seventy-eight (54%) of the respondents made MAEs in the last 12 months. Only 10 (5%) of the 200 observed nurses were administered medications without any breach in any of the six rights of medication administration. Factors like poor knowledge (AOR = 5.98; 95% CI (2.39,14.94)), poor communication (AOR = 2.94; 95% CI (1.34, 6.46)), stress (AOR = 5.41; 95% CI (2.53, 11.57)), interruption during medication administration (AOR = 4.70, 95% CI (2.42, 9.10)), and night shift (AOR = 2.79, 95% CI (1.42, 5.46)) were significantly associated with MAE.

Conclusions

The magnitude of MAE was high. Poor knowledge, poor communication, stress, night shift, and interruption were significantly associated with MAEs. Strengthening institutional medication administration regulations and guidelines and minimizing interruption during medication administration would help minimize MAEs.

Exploring Health Care Professionals' Perceptions of Incidents and Incident Reporting in Rehabilitation Settings

OBJECTIVES

Research exploring patient safety in rehabilitation settings is limited. This study's aim was to describe team members' perceptions of incidents and incident reporting in rehabilitation settings.

METHODS

Semistructured interviews were conducted with 18 health care professionals from multiple rehabilitation units (medical, neurological, and orthopedic) at 2 inner-city rehabilitation centers. Five hypothetical scenarios were presented to participants during the interviews. Participants were asked to classify the scenarios and whether they would report any identified incidents. Data were analyzed using a descriptive thematic approach.

RESULTS

Participants classified events based on 2 parameters: the nature of the outcome and deviation from professional practice. Factors influencing participants' decisions to file incident reports included their classification of the events in the scenarios (i.e., events classified as critical incidents were more often reported than those classified as incident or near miss); the severity of the impact on the client; and their profession's perceived role in reporting specific incidents. When participants said they would report incidents, all agreed that they would report only objective facts.

CONCLUSIONS

The study findings demonstrate gaps between incident-reporting policy and practice, and opportunities to address these gaps. Organizational leaders can work with all health care professions to support their roles in reporting. Interprofessional team building, focused on valuing all team members, may improve interprofessional communication and reporting. Setting standards for classifying events could increase consistency in reporting. Ultimately, encouraging reporting of near misses and incidents can create a culture of learning focused on problem solving and improved patient safety.

A systematic review of activities undertaken by the unregulated Nursing Assistant

AIM

To identify activities performed by Nursing Assistants in acute and primary healthcare.

DESIGN

Systematic review.

DATA SOURCES

The databases MedLine/PubMed, ProQuest and Google Scholar were searched for empirical studies published in the English language between 2008 and 2018 that addressed the work of Nursing Assistants.

REVIEW METHODS

From an initial yield of 2,944 publications, 71 publications were retained for full text review and 20 publications included in this review. Activities undertaken by Nursing Assistants from eight countries were extracted and categorized into one of six categories.

RESULTS

Over 200 activities were identified as being delegated to Nurse Assistants globally. Many of these activities are beyond the training of the Nurse Assistant and are being performed with limited Registered Nurse supervision.

CONCLUSION

Patient safety is at risk. Nurse Assistants' roles vary widely, with some seeing their role as similar to that of a regulated nurse, while recognizing their need for additional training.

IMPACT

Over 31% of activities delegated to Nurse Assistants require skill and comprehension beyond their level of training. Patients and regulated nurses need to have confidence that Nursing Assistants responsible for care provision are appropriately trained and practicing within regulatory standards.

Impact of interruptions on the duration of nursing interventions: A study in a chemotherapy unit

Abstract Objective: To investigate interruptions during nursing interventions in a chemotherapy unit (sources and causes); measure their frequency, duration and the total elapsed time to complete the interventions. Method: This is an observational analytical study performed using a digital stopwatch. It was conducted in a teaching hospital between 2015/2016. The interventions performed and their interruptions were mapped and classified according to the Nursing Interventions Classifications (NIC) taxonomy. Results: There were 492 interruptions recorded in the 107 hours observed, especially in indirect care interventions. They were mainly caused by nursing professionals (n = 289; 57.3%) to supply materials (n = 65; 12.8%) and exchange care information (n = 65; 12.8%). The duration of interruptions ranged from 0:08 to 9:09 (average 1:15; SD 1:03) minutes. On average, interventions took 2:16 (SD 0:27) minutes to complete without interruption; however, the average was 5:59 (SD 3:01) minutes when interrupted. Conclusion: The interruptions were constant during the nursing work in the chemotherapy unit, including during the preparation and administration of medications, and increased the time to complete the interventions by an average of 163.9%.

Interruptions during intravenous medication administration: A multicentre observational study

AIMS

The aim of this study was to determine the frequency and cause of interruptions during intravenous medication administration, which factors are associated with interruptions and to what extent interruptions influence protocol compliance.

BACKGROUND

Hospital nurses are frequently interrupted during medication administration, which contributes to the occurrence of administration errors. Errors with intravenous medication are especially worrisome, given their immediate therapeutic effects. However, knowledge about the extent and type of interruptions during intravenous medication administration is limited.

DESIGN

Multicentre observational study.

METHODS

Data were collected during two national evaluation studies (2011 - 2012 & 2015 - 2016). Nurses were directly observed during intravenous medication administration. An interruption was defined as a situation where a break during the administration was needed or where a nurse was distracted but could process without a break. Interruptions were categorized according to source and cause. Multilevel logistic regression analyses were conducted to assess the associations between explanatory variables and interruptions or complete protocol compliance.

RESULTS

In total, 2,526 intravenous medication administration processes were observed. During 291 (12%) observations, nurses were interrupted 321 times. Most interruptions were externally initiated by other nurses (19%) or patients (19%). Less interruptions occurred during the evening (odds ratio: 0.23 [95% confidence interval: 0.08-0.62]). Do-not-disturb vests were worn by 61 (2%) nurses. No significant association was found between being interrupted and complete protocol compliance.

CONCLUSION

An interruption occurred in every eight observed intravenous medication administration, mainly caused by other nurses or patients. One needs to consider critically which strategies effectively improve safety during the high-risk nursing-task of intravenous medication administration.

Supply and demand: application of Lean Six Sigma methods to improve drug round efficiency and release nursing time

Objective

To improve efficiency, reduce interruptions and reduce the time taken to complete oral drug rounds.

Design

Lean Six Sigma methods were applied to improve drug round efficiency using a pre- and post-intervention design.

Setting

A 20-bed orthopaedic ward in a large teaching hospital in Ireland.

Participants

Pharmacy, nursing and quality improvement staff.

Intervention(s)

A multifaceted intervention was designed which included changes in processes related to drug trolley organization and drug supply planning. A communications campaign aimed at reducing interruptions during nurse-led during rounds was also developed and implemented.

Main outcome measure(s)

Average number of interruptions, average drug round time and variation in time taken to complete drug round.

Results

At baseline, the oral drug round took an average of 125 min. Following application of Lean Six Sigma methods, the average drug round time decreased by 51 min. The average number of interruptions per drug round reduced from an average of 12 at baseline to 11 following intervention, with a 75% reduction in drug supply interruptions.

Conclusions

Lean Six Sigma methodology was successfully employed to reduce interruptions and to reduce time taken to complete the oral drug round.

Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration

BACKGROUND

Because of the high frequency of interruptions during medication administration, the effectiveness of strategies to limit interruptions during medication administration has been evaluated in numerous quality improvement initiatives in an effort to reduce medication administration errors.

OBJECTIVES

To evaluate the effectiveness of evidence-based strategies to limit interruptions during scheduled, peak medication administration times in 3 progressive cardiac care units (PCCUs). A secondary aim of the project was to evaluate the impact of limiting interruptions on medication errors.

METHODS

The percentages of interruptions and medication errors before and after implementation of evidence-based strategies to limit interruptions were measured by using direct observations of nurses on 2 PCCUs. Nurses in a third PCCU served as a comparison group.

RESULTS

Interruptions (P < .001) and medication errors (P = .02) decreased significantly in 1 PCCU after implementation of evidence-based strategies to limit interruptions. Avoidable interruptions decreased 83% in PCCU1 and 53% in PCCU2 after implementation of the evidence-based strategies.

CONCLUSIONS

Implementation of evidence-based strategies to limit interruptions in PCCUs decreases avoidable interruptions and promotes patient safety.

Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia

BACKGROUND

During medication administration process, including preparation, administration, and documentation, there is high proportion of work interruption that results in medication administration errors that consequently affect the safety of patients. Thus, the main purpose of this study was to assess the prevalence of work interruption and associated factors during medication administration process.

METHODS

A prospective, observation-based, cross-sectional study was conducted on 278 nurses. Structure observational sheet was utilized to collect data. EPI Info version 3.5.3 and SPSS version 20 software were utilized for data entry and analysis, respectively. Binary and multivariable logistic regression were fitted to identify the associated factors using an odds ratio and 95% CI.

RESULTS

The incidence of work interruption was found to be 1,152 during medication administration process. Of this, 579 (50.3%) were major/severe work interruptions. Unit of work, day of the week, professional experience, perceived severity of work interruption, source/initiator of interruption, and secondary tasks were factors significantly associated with major work interruptions at p < 0.05.

CONCLUSION

In this study, more than half of work interruption was major/severe. Thus, the authors suggest raising the awareness of nurses regarding the severity of work interruptions, with special attention to those who have lower work experience, sources of interruption, and secondary tasks by assigning additional nurses who manage secondary tasks and supportive supervision.

Interruptions and their effects on the dynamics of the nursing work

Objectives

To investigate the nurses' perception about interruptions during the workflow and their implications on the professional practice environment.

Methods

A survey was conducted with 133 nurses in a school hospital in the state of São Paulo from October 2015 to March 2016, through the use of a self-administered questionnaire. For data analysis, Chi-square and Fischer tests have been used.

Results

Most of the nurses have reported frequent and recurring interruptions during their work activities. The interruptive processes are more frequent during the documentation process (n=118; 91.5%) and guidance to the patient/family (n=58; 45%). They are caused by the ringing of the phone (n=114; 87%), and by problem solving in the unit (n=107; 81.7%).

Conclusions

According to the nurses' opinion, the interruptive processes have repercussions on the working dynamics, on the caring process and on the patient's safety.

Driven to distraction: The nature and apparent purpose of interruptions in critical care and implications for HIT

OBJECTIVES

To examine the apparent purpose of interruptions in a Pediatric Intensive Care Unit and opportunities to reduce their burden with informatics solutions.

MATERIALS AND METHODS

In this prospective observational study, researchers shadowed clinicians in the unit for one hour at a time, recording all interruptions participating clinicians experienced or initiated, their starting time, duration, and a short description that could help to infer their apparent purpose. All captured interruptions were classified inductively on their source and apparent purpose and on the optimal representational media for fulfilling their apparent purpose.

RESULTS

The researchers observed thirty-four one-hour sessions with clinicians in the unit, including 21 nurses and 13 residents and house physicians. The physicians were interrupted on average 11.9 times per hour and interrupted others 8.8 times per hour. Nurses were interrupted 8.6 times per hour and interrupted others 5.1 times per hour. The apparent purpose of interruptions included Information Seeking and Sharing (n=259, 46.3%), Directives and Requests (n=70, 12%), Shared Decision-Making (n=49, 8.8%), Direct Patient Care (n=36, 6.4%), Social (n=71, 12.7%), Device Alarms (n=28, 5%), and Non-Clinical (n=10, 1.8%); 6.6% were not classified due to insufficient description. Of all captured interruptions, 29.5% were classified as being better served with informational displays or computer-mediated communication.

CONCLUSIONS

Deeper understanding of the purpose of interruptions in critical care can help to distinguish between interruptions that require face-to-face conversation and those that can be eliminated with informatics solutions. The proposed taxonomy of interruptions and representational analysis can be used to further advance the science of interruptions in clinical care.

Interruptions of nurses' activities and patient safety: an integrative literature review

OBJECTIVES

to identify characteristics related to the interruption of nurses in professional practice, as well as to assess the implications of interruptions for patient safety.

METHOD

integrative literature review. The following databases were searched: Pubmed/Medline, LILACS, SciELO and Cochrane Library, using the descriptors interruptions and patient safety. An initial date was not established, but the final date was December 31, 2013. A total of 29 papers met the inclusion criteria.

RESULTS

all the papers included describe interruptions as a harmful factor for patient safety. Data analysis revealed three relevant categories: characteristics of interruptions, implications for patient safety, and interventions to minimize interruptions.

CONCLUSION

interruptions favor the occurrence of errors in the health field. Therefore, there is a need for further studies to understand such a phenomenon and its effects on clinical practice.

Effectiveness of an improvement programme to prevent interruptions during medication administration in a paediatric hospital: a preintervention-postintervention study

OBJECTIVE

To assess the effectiveness of an improvement programme to reduce the number of interruptions during the medication administration process in a paediatric hospital.

DESIGN AND METHODS

A prestudy-post study design was used to monitor nursing interruptions during medication cycles in a paediatric hospital. Interruptions were reported on an observation sheet (MADOS-P) adapted to the paediatric context.

SETTING

A 600-bed tertiary paediatric research hospital in Italy.

INTERVENTION

The interventions included a yellow sash worn by nurses during medication cycles, a yellow-taped floor area indicating the 'No interruption area', visual notices in the medication areas, education sessions for healthcare providers and families, patient and parent information material.

RESULTS

225 medication cycles were observed before the intervention (T0) and 261 after the intervention (T1). The median of interruptions occurring in each cycle decreased significantly from baseline to postintervention (8.0 vs 2.0, p=0.002), as the rate ratios (interruptions/patient post-pre ratio: 0.34; interruptions/medication post-pre ratio: 0.37; interruptions/hour of medication cycle post-pre ratio: 0.53, p<0.001). During preintervention, the main causes of interruptions were 'other patients' (19.9%), 'other nurses' (17.2%) and 'conversation' (15.7%); during postintervention, they were 'other nurses' (26.1%), 'conversation' (18.2%) and 'other patients' (17.4%).

CONCLUSIONS

This bundle of interventions proved to be an effective improvement programme to prevent interruptions during medication administration in a paediatric context.

Interruptions and medication administration in critical care

BACKGROUND

Medication administration has inherent risks, with errors having enormous impact on the quality and efficiency of patient care, particularly in relation to experience, outcomes and safety. Nurses are pivotal to the medication administration process and therefore must demonstrate safe and reliable practice. However, interruptions can lead to mistakes and omissions.

AIM

To critique and synthesize the existing literature relating to the impact that interruptions have during medication administration within the paediatric critical care (PCC) setting.

SEARCH STRATEGY

Key terms identified from background literature were used to search three electronic databases (Medline, CINHAL and BNI). Selected sources were critically appraised using the Critical Appraisal Skills Programme (CASP) tool.

FINDINGS

There is confusion within the literature concerning the definition of interruption. Moreover, an assumption that all interruptions have a negative impact on patient safety exists. The literature identifies the multi-dimensional nature of interruptions and their impact on medication administration and patient safety. The cumulative effect of interruptions depends on what type of task is being completed, when it occurs, what the interruption is and which method of handling is utilized. A conceptual schema has been developed in order to explicate the themes and concepts that emerged.

CONCLUSIONS

This review summarizes debates within the international arena concerning the impact of interruptions on medication administration. However, conclusions drawn appear applicable in relation to practice, education and future research to other critical care settings.

RELEVANCE TO CLINICAL PRACTICE

Findings show that no single strategy is likely to improve the negative effect of interruptions without focus on patient safety. Practice education to improve team building interactions is required that equips nurses with the skills in managing interruptions and delegating high priority secondary tasks.

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence

BACKGROUND

Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence.

OBJECTIVE

This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings.

DATA SOURCES

Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013.

STUDY SELECTION

Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail.

DATA APPRAISAL AND SYNTHESIS METHODS

A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used.

RESULTS

Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies.

LIMITATIONS

As only English language publications were included, some relevant studies may have been missed.

CONCLUSIONS

Limited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoretical focus is needed to investigate the MAE causation pathway, with an emphasis on ensuring interventions designed to minimise MAEs target recognised underlying causes of errors to maximise their impact.