Posted by: Salvatore J. Zambri, founding partner
As reported recently by a HealthDay report, Patient Safety and Quality Healthcare article and Archives of Internal Medicine abstract, distractions and interruptions for nurses during medication preparation and administration lead to a higher rate of procedural failures and clinical errors. Although patient safety experts have warned about these dangers for a number of years, this is the first research to actually confirm that relationship. Common distractions include staff inquiries, stopping to search for missing drugs or supplies, and responding to phone calls or pages. According to Patient Safety and Quality Healthcare Reports, nurses view these types of interruptions as part of the daily work and don’t seek to control them–a scary thing.
Following are significant observations from the study:
- "Errors were classified as either "procedural failures," such as failing to read the medication label, or "clinical errors," such as giving the wrong drug or wrong dose.
- Only one in five drug administrations (19.8 percent) was completely error-free, the study found.
- Interruptions occurred during more than half (53.1 percent) of all administrations, and each interruption was associated with a 12.1 percent increase, on average, in procedural failures and a 12.7 percent increase in clinical errors.
- Most errors (79.3 percent) were minor, having little or no impact on patients, according to the study. However, 115 errors (2.7 percent) were considered major errors, and all of them were clinical errors.
- Failing to check a patient’s identification against his or her medication chart and administering medication at the wrong time were the most common procedural and clinical glitches, respectively, the study reported."
"Nurses reported that study observations were made during a comparatively non-chaotic days when they had not been working extremely busy shifts. Investigators felt that if the nurses had been observed during a more intensely busy shift, more errors would have been seen." The value of this new study "lends important evidence to identifying the contributing factors and circumstances that can lead to a medication error," said Carol Keohane, Program Director for the Center of Excellence for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston.
Several hospitals have recommended possible means to avoid excessive interruptions, such as "no interruption zones," "do not disturb vests," "medication pass time-out," or "protected hour" for medication administration. This issue must be taken seriously by hospitals and other medical facilities otherwise serious medical errors will continue to occur. According to the reputed Institutes of Medicine, approximately 98,000 Americans are killed every year as a result of medical errors. Patient safety needs to be a priority.
Do you have any questions about this post?
About the author:
Mr. Zambri is a Past-President of the Trial Lawyers Association of Metropolitan Washington, D.C. He has been acknowledged by Washingtonian magazine as a "Big Gun" and among the "top 1%" of all of the more than 80,000 lawyers in the Washington metropolitan area. The magazine also acknowledges him as "one of Washington’s best–most honest and effective lawyers" who specializes in medical malpractice matters, product liability claims, and serious automobile accident claims. Mr. Zambri has also been repeatedly named a "Super Lawyer" by Law and Politics magazine–a national publication that honors the top lawyers in America.
Mr. Zambri is regularly asked to present seminars to lawyers and doctors, as well as both medical and law students concerning medication errors, medical malpractice litigation, and safety improvements.
If you have any questions about your legal rights, please email Mr. Zambri at email@example.com or call him at 202-822-1899.