The impact of interruptions on medication errors in hospitals: an observational study of nurses.

AIM

To explore interruptions during medication preparation and administration and their consequences.

BACKGROUND

Although not all interruptions in nursing have a negative impact, interruptions during medication rounds have been associated with medication errors.

METHOD

A non-participant observational study was undertaken of nurses conducting medication rounds.

RESULTS

Fifty-six medication events (including 101 interruptions) were observed. Most medication events (99%) were interrupted, resulting in nurses stopping medication preparation or administration to address the interruption (mean 2.5 minutes). The mean number of interruptions was 1.79 (SD 1.04). Thirty-four percent of medication events had at least one procedural failure, while 3.6% resulted in a clinical error.

CONCLUSIONS

Our study confirmed that interruptions occur frequently during medication preparation and administration, and these interruptions were associated with procedural failures and clinical errors. Nurses were the primary source of interruptions with interruptions often being unrelated to patient care.

IMPLICATIONS FOR NURSING MANAGEMENT

This study has confirmed that interruptions are frequent and result in clinical errors and procedural failures, compromising patient safety. These interruptions contribute a substantial additional workload to medication tasks. Various interventions should be implemented to reduce non-patient-related interruptions. Medication systems and procedures are advocated, that reduce the need for joint double-checking of medications, indirectly avoiding interruptions.