Interruptions associated with medication errors

January 01, 0001

Interruptions associated with medication errors

These Australian authors tested the hypothesis that interruptions during medication administration increase errors. They performed an observational study of nurses preparing and administering medications in 6 wards at 2 major teaching hospitals in Sydney. Procedural failures and interruptions were recorded during direct observation. Clinical errors were identified by comparing observational data with patients' medication charts. A volunteer sample of 98 nurses (representing a participation rate of 82%) were observed preparing and administering 4271 medications to 720 patients over 505 hours from September 2006 through March 2008.

They found: "Each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. The association between interruptions and clinical errors was independent of hospital and nurse characteristics. Interruptions occurred in 53.1% of administrations. Of total drug administrations, 74.4% (n = 3177) had at least 1 procedural failure. Administrations with no interruptions (n = 2005) had a procedural failure rate of 69.6% (n = 1395), which increased to 84.6% (n = 148) with 3 interruptions. Overall, 25.0% (n = 1067) of administrations had at least 1 clinical error. Those with no interruptions had a rate of 25.3% (n = 507), whereas those with 3 interruptions had a rate of 38.9% (n = 68). Nurse experience provided no protection against making a clinical error and was associated with higher procedural failure rates. Error severity increased with interruption frequency. Without interruption, the estimated risk of a major error was 2.3%; with 4 interruptions this risk doubled to 4.7%."

The authors concluded: "Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors."

This is important evidence to be used to create safer health care delivery systems.

For the full abstract, click here.

Arch Intern Med 170(8):683-690, 26 April 2010 © 2010 to the American Medical Association
Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Johanna I. Westbrook, Amanda Woods, Marilyn I. Rob, William T. M. Dunsmuir, Richard O. Day. Correspondence to Dr. Westbrook: [email protected]

Category: HSR. Health Services Research. Keywords: interruptions, medication errors, clinical errors, procedural failures, observational study, journal watch.
Synopsis edited by Dr Linda French, Toledo, Ohio. Posted on Global Family Doctor 18 May 2010

Pearls are an independent product of the Cochrane primary care group and are meant for educational use and not to guide clinical care.