Thursday, 17 June 2010

Interruptions and Medication Errors

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.

Ha. I will have about 38 interruption during the course of the 0800 drug round.

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."
 Yeah you're telling me.
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."
 Yeah one problem with that.  The public (who cannot see both sides of the issue will accuse us of "lacking in compassion" for prioritising patient safety over customer service for visitors.
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.

So does anyone want to come on here and tell me that airline pilots are lacking in compassion because they won't converse with the passengers during take off?  Oh wait.  You have respect for airline pilots and understand that they have a lot of responsibility and that there are grave consequences when they make errors.  You don't understand this about registered nurses.  Nor do you have that kind of respect for doctors anymore.

When one junior doctor is running between over 250 patients you throw tantrums when he won't immediately drop what he is doing to speak to you. Again.  When it takes him 4 hours to meet with you because he has  critically ill patients on this 16 hour shift of his you call him lazy.  

Try that to get away with that rubbish next time you are on a passenger jet.  Start screaming at the stewardess and demand that the pilots come and speak to you this this just as they are doing their pre flight checks.  Yell and carry on  that the airline staff are lacking and compassion and uncaring because they won't meet your demands.  Justify it by saying that you are "scared" and "stressed".You will be on the floor, belly down and  handcuffed with an airmarshalls boot on your back before anyone can say "obnoxious ".   This is because the airlines put SAFETY as a priority over CUSTOMER SERVICE and there are punishments for those in charge at management level.  Hospitals don't do this.  That is why thousands of people die  needlessly every year in hospitals and are hardly EVER dying needlessly 30,000 feet above the atlantic ocean packed like sardines in a flying missle carrying fuckloads of flammable fuel.

Go ahead.  I double dare you.  Interrupt a stewardess while she is doing the airline safety demo and demand a ginger ale.  When she says "no". Roll you eyes, tell her she is lazy and tell her bosses she couldn't "be bothered".   The airline will deal with you if you act like that.  Stewardesses are in a situation where it is very unlikely that anything will go wrong.  In hospitals is very likely that things will go wrong.  Yet they have these kinds of protections and they also have ratio laws that limit the number of passengers per stewardesses.  Nurses have no control over the number of patients they are responsible for whilst on duty.

I wonder how much of this lack of respect for hospital staff  is down to medical dramas that depict nurses as a gaggle of people standing around the nurses station who have nothing to do but wait for a visitor or a patient to require service.  They depict one patient that has a team of doctors at his bedside at all times carrying out all bedside care i.e. monitoring vent settings and drip calculations.  No wonder the public's mind is warped.  No wonder they get pissed off at the staff.  Over at allnurses many of the nurses are saying that the only way to get through and keep your patients safe is to avoid all eye contact with the relatives and keep moving.  This isn't because of the reseasonable visitors who ask questions and mention concerns.  It is because of the visitors who are unreasonable and who are not kicked into line by management. Everybody suffers...the patients....the good relatives....and the Nurses and Doctors.  I think they have a bigger problem with these kinds of relatives across the pond.

Even without interruptions the number of mistakes are rife.  I would be willing to bet that most of those are down to the Nurse rushing to get everything done for too many patients rather than nurse incompetence.  Then you have to take into account that the RN has to take over pharmacy, physio, housekeeping, and clerking duties when they are short staffed.  The short cuts we have to take are unreal. And we are still not giving the patients the amount of time that they expect.

I wonder if Virgin Atlantic hires RN's?  I wouldn't mind an Air Marshall to have my back when I am at work.  Should I talk about violence against staff in my next post along with our lack of security guards  or do you want to hear about the young low paid not yet a care assistant who really REALLY  angered  a patient?  All without breaching confidentiallity of course.


Miss_Nix said...

I vote cadet. I haven't commented on your blog before but am fascinated by your entries. It is important to see woes from both sides of the fence and I always think of your blog when people complain to me about their hospital experiences and I tell them to read it!

GrumpyRN said...

Nah! Let's have the Cadet, I have been on the receiving end of violence and abuse from relatives but always like to hear when patients get pissed off. kind of nice when you can think to yourself, "Well they deserved THAT!".

Dino-nurse said...

I have friends who are flight attendants and they cannot believe how much crap nurses etc have to put up with. I have spent yet another morning trawling through the latest batch of IR1s from medicine...most are medication errors or patients falling over. ALL can be attributed to lack of nursing staff but the Trust no longer accept that as an explanation. I have to be creative and use big words to say the same thing. So am thumbing through a thesarus as I go...whats a big word for dumbass?

Nurse Anne said...

The patient should have hit the cadet actually. But she was a nice lady. Okay. I'll get to it.

Nurse Anne said...

" ALL can be attributed to lack of nursing staff but the Trust no longer accept that as an explanation"

Neither will my trust. When short staffing is mentioned to the higher ups they roll their eyes, snort, walk away, or chuckle.

Anonymous said...

darling Nurse Cadets..........only 16 and all rearing to go and do nursing via 1000 different NVQ access courses or what ever. a patient pooed himself and the cadet asked the cleaner to come and clean him up. I explained "no its nurse who clean up shit" poor littel darling! she was horrified. I guess she thought it would be like Holby city.

Nurse Anne said...

Once a patient arrested in front of my eyes. The only person around was a 16 year old cadet. I shouted at her to put the crash call out while I started CPR. Her eyes got as big as saucers and she just ran off in the other direction away from the phone. I got her sacked for that.

We have one are two that are absolutely fabulous. They are like little diamonds in a sea of shit. They really want to be nurses and take it seriously.

Anonymous said...

hen I was in hospital many years ago there was always 2 nurses issuing medication to ensure there were no errors. The trolley was always locked if for any reason it had to be left unattended.

Last time there were far fewer nurses and medication was issued by one nurse with no-one there to do any cross-checking. When she was away from the trolley it was left unlocked and unattended, even if she was called away from the ward.

A definite deterioration in standards due to the lack of nurses.

jackie-who shags a phychi nurse said...

thing is we are all so PRESSURED! i went to the ward to arrange a transfer of my patient from icu to ward. nurse is on her drug round. if i dont catch her now, it will be protected mealtimes, then she will be on her break, then there will be a ward round blah blah. thus i interupted her during tbe drug round, told her i was bringing in an icu patient. and asked her to ensure her bed had an oxygen supply and some suction. then i went and moved the patient. and set up the oxygen and suction myself as it still hadnt been done. Still not nurses around to take handover. so i just left the patient. had to get back........SO FUCKING MUCH TO DO, got to admit the next patient coz its breaching, got to listen to the little cadet crying at her first death, got to stop the newly qualified nurse giving insulin at 50ml per hour instead of 5. got to phone the nurse bank and get some staff. and so it continues. sorry

Nurse Anne said...

I hear you. There is so much going at once that it is impossible. We are all so desperate for more qualified nurses at ward level. This is the whole problem. I can't believe how rushed I am and how fast I am moving sometimes. Even in a 12 hour shift there is no time.

Dino-nurse said...

Time and time again I have had patients transferred from ICU to the ward and the nurse escort has come back with a list of things she had to do once they got to the ward. This impacts on everyone. ICU is a nurse down until the escort returns, an admission is often delayed because of this. The wards are pitifully understaffed so we are putting the patient at risk by transferring them. The strain on ward staff is visible as you walk onto the ward. God knows what the patients think. We always stress to families that staffing levels on the ward are not the same as ICU because the patients aren't as sick. Little white lies to ease our minds. Wards are often full of very sick patients but this falls on deaf ears in terms of staffing.

jackie said...

any one free for a bank shift on sunday? seems the whole world wants to watch the football even agency nurses on £32 per hour.

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