By Dr. Ananya Mandal, MD
In a study published in the journal Archives of Internal Medicine on the 26th of April the causes of “procedural failure and clinical error” by nurses in Australian hospitals were analyzed. The study found that nurses made at least one mistake or oversight in a whopping 80.2% of cases where they were administering drugs or other therapy to patients. These mistakes could range from not checking the patient’s identity before giving the drug to not washing hands. Researchers say that in some cases these mistakes could be fatal.
Professor Johanna Westbrook from the University of Sydney's Health Informatics Research and Evaluation Unit and the lead author of the study said that the more a nurse was interrupted in her work the more likely it was that they would make errors. “In 80 per cent of administrations of medication there was at least one procedural failure or one clinical error… What we showed is that if you were interrupted you we more likely to make one of those errors…We found as interruptions increased within a single drug administration, the greater the severity of error…(And) the risk of a patient experiencing a major clinical error doubled in the presence of four or more interruptions,” she said. She specified that common interruptions were when “someone came to ask them a question and so they stopped what they were doing, or a patient asked them something or an alarm went off in the room and so they stopped administering a drug.” She said that there are hospitals that provide “Do not disturb” vests to nurses while they administer drugs to minimize errors. But she believes that, “Not any one strategy is going to solve the problem…And because we haven't had the evidence (in the past) we haven't been educating clinicians about the potential dangers of interrupting each other.” 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 medication and procedural errors (79.3%) were minor, having little or no impact on patients. However, 115 errors (2.7 percent) were considered major errors, and all of them were clinical errors. In 4.1% there was an error in timing of the drug which could be dangerous to the patients. 35.7% nurses made mistakes in dosing while setting up an intravenous drip – another dangerous error.
For the study she and her colleagues studied nearly 100 nurses over nearly two years in two undisclosed Australian hospitals. During this time the nurses administered nearly 4300 medications to nearly 700 patients. She cited the “enormous pressure” that the nurses worked under as the main cause for such results.
Carol Keohane, program director for the Center of Excellence for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston commended the study and said that this “lends important evidence to identifying the contributing factors and circumstances that can lead to a medication error.”
Linda Flynn, associate professor at the University of Maryland School of Nursing in Baltimore also added, “Patients and family members don't understand that it's dangerous to patient safety to interrupt nurses while they're working… 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.”
Julie Kliger, program director of the Integrated Nurse Leadership Program at the University of California, San Francisco said that there was a level of complacence among nurses, healthcare workers, patients and their families when it came to drug administration. “We need to reframe this in a new light, which is, it's an important, critical function… 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.” She suggested a concept of “protected hour” for nurses when they can focus only on drug administration could be a solution.
On the other hand Westbrook also said that not all questions and interruptions are irrelevant. “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 added.