SAN FRANCISCO, CA (ASRN.ORG) --For nurses at San Francisco's St. Rose Hospital, chaos was the rule rather than the exception. And that's typical, according to a new study.
"You've got your pill cups, she's got hers. You're talking about the weekend, the phone is ringing, doctors are asking questions," recalls Linda Aug, supervisor of the hospital's medical-surgical department. "Interruptions were normal. We thought they were OK."
But she was startled when her department signed on for the University of California, San Francisco's Integrated Nurse Leadership Program and tracked how distracted their staff of 300 nurses actually were.
Nurses in the department, who oversee about 120 beds, were interrupted at least once "around half the time" they doled out medications, Aug stated.
"The problem was significant," she said.
And the issues plaguing St. Rose are in line with the results of an Australian study on rates of error among nurses preparing and administering medication.
Interruptions have long been blamed for medical errors. But this research is the first to directly examine the link between distractions and mistakes in nursing care.
The research team observed 98 nurses in six different wards at two Australian hospitals. Over the course of 505 hours, the nurses prepared and administered more than 4,000 medications for 720 patients.
Errors in procedure (such as failing to read a medicine's label) and in clinical care (such as the dosage or the drug administered) were recorded, as were any interruptions.
For each interruption, there was a 12 percent increase in procedural errors and a 12.7 percent increase in clinical errors. Nurses were interrupted at least once during more than half of all drug administrations. A startling 74 percent of all administrations were marred by at least one procedural slip-up.
The most common error in procedure was not double-checking patients' names against their medical chart, with more experienced nurses more likely to make the mistake.
Clinical mistakes occurred in 25 percent of the observed cases. But that percentage shot to nearly 40 percent when a nurse experienced three or more interruptions during the procedure.
Of all the errors, 80 percent were categorized by the researchers as minor; only 2.7 percent were deemed "major" slip-ups.
But Johanna Westbrook, a professor who led the study, isn't reassured by the relatively benign consequences that followed most of the errors.
"The high rate of overall errors is important as the mechanisms which cause serious errors are the same as those that cause errors with only minor consequences," she said. "One of the challenging aspects of medication safety is that the same error may have a serious outcome for one patient, but the same type of error may have no or only a minor consequence for another."
Researchers didn't note the specific causes of the interruptions, but a 2009 Canadian Study found that cues from the external environment, like monitor alarms, were the culprits in 37 percent of errors due to interruption. Patients and their families accounted for a combined 17 percent of all instances.
Indeed, a day in the life of a hospital nurse is rife with interference. Overhead pages, alarms, and communication with physicians, patients and families, as well as nursing colleagues, are only a few of the factors that pose a distraction danger.
Julie Kliger, the program director for the Integrated Nurse Leadership Program and an independent heath care consultant, authored a commentary alongside the study. Kliger's program trains front-line staffers (including doctors, nurses and pharmacists) in leadership and problem-solving. She is emphatic that a hospital-wide approach is the only solution.
"You can't just tell people to do better; you need to locate the source of the problem," she said. "In this case, care centers need to recognize that medication administration is a critical and a high-risk activity, and needs to be treated as such."
Kliger's program spurred the nurses at St. Rose to institute hour-long "no interruption" periods for medication delivery. An overhead announcement, issued for five out of every 24 hours, requests that nurses be left alone to do their rounds.
The results have been so successful that every department at St. Rose has implemented some variation of the initiative. Nurses now work in silence at medication trolleys, wear badges to designate that they're administering meds and deliver drugs to one patient at a time.
"Patients love it," Aug said. "They feel safer, and they get more one-on-one, devoted attention to ask questions or benefit from education about what exactly they're being given, why, what the side effects are."
And Kliger is adamant that, in addition to offering more reliable medical care, policies to minimize errors will also be a financial boon for hospitals. They would pay out less, she said, to compensate for errors and create a more streamlined, efficient care-giving system.
"Nurses aren't running around trying to do everything at once anymore," she said. "That's better patient care, and it means those critical tasks are done faster and more effectively."
Copyright 2010- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved
Agency San Francisco, Inc.
Agency San Francisco, Inc.
San Francisco, California
Charles L. Berman
Liz Di Bernardo
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