Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

BACKGROUND: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. OBJECTIVE: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. METHODS: The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. RESULTS: Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. CONCLUSIONS: Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

OBJECTIVE: To determine what components of a checklist contribute to effective detection of medication errors at the bedside. DESIGN: High-fidelity simulation study of outpatient chemotherapy administration. SETTING: Usability laboratory. PARTICIPANTS: Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors. MAIN OUTCOME MEASURES: Rates of specified types of errors related to medication administration. RESULTS: As few as 0% and as many as 90% of each type of error were detected. Error detection varied as a function of error type and checklist used. Specific step-by-step instructions were more effective than abstract general reminders in helping nurses to detect errors. Adding a specific instruction to check the patient's identification improved error detection in this category by 65 percentage points. Matching the sequence of items on the checklist with nurses' workflow had a positive impact on the ease of use and efficiency of the checklist. CONCLUSIONS: Checklists designed with explicit step-by-step instructions are useful for detecting specific errors when a care provider is required to perform a long series of mechanistic tasks under a high cognitive load. Further research is needed to determine how best to assist clinicians in switching between mechanistic tasks and abstract clinical problem solving.

Interruptions during the delivery of high-risk medications.

OBJECTIVE: The goal of this study was to assess the nature and frequency of interruptions during medication administration and the interruptions' effects on task efficiency to guide healthcare managers/executives in improving patient safety and staff productivity. BACKGROUND: Interruptions have been identified as causal factors in medication administration errors. Research, however, is needed to assess the nature and frequency of interruptions throughout specific stages of the medication administration process and to develop mitigation interventions. METHOD: A direct observation study was conducted to document the nature, frequency, and timing of interruptions during specific stages of medication administration in a chemotherapy daycare unit. RESULTS: Nurses were interrupted, on average, 22% of their time and were frequently interrupted while performing safety-critical tasks. Task completion times were greater for interrupted tasks than for uninterrupted tasks. CONCLUSION: Nurses are frequently interrupted during safety-critical stages of medication administration, which decreases task efficiency and could lead to adverse events.