Medication Errors and Interruptions

How do medication errors occur? Think about the typical healthcare scene:

The phone is ringing at the nurse’s station. The patients are putting on their lights asking for help. The IV pump is alarming. In the midst of this, the nurse is trying to give medications. A study showed that interrupting a nurse just once in the process of giving medications led to a 12% increase in procedural errors, such as omitting a step in medication preparation like confirming the patient’s identity. There was a 13% increase in clinical errors, such as giving the wrong dose or wrong medication. The more interruptions there were, the more errors occurred.

Analysis of medication error case

Legal nurse consultants reviewing a case involving a medication error will rarely be able to understand the environment in which the medication error occurred. A defendant nurse may not remember what led up to the error, or may testify that it was a busy shift. The LNC may be surprised to learn that the nurse defendant was an experienced nurse. In the study, the researchers found that part time and less-experienced nurses had lower rates of procedural failures. They speculated that full time, experienced nurses are more likely to believe that they can visually identify their patients and bypass verifying identity.

Why do experienced nurses make more medication errors?

Do more experienced nurses become complacent? Take shortcuts? Get careless? Are they interrupted more because they may have a higher status within the nursing hierarchy?

How can nurses be protected from the risks of distraction leading to medication errors? Is it realistic to expect a nurse who is giving medications to not take phone calls from a physician, not answer pages, or not perform other nursing tasks? How much can be controlled? Will the nursing environment respect the needs of the nurse to not be distracted or interrupted?

What do you think? Share a comment.

Pat Iyer MSN RN LNCC used to work on busy medical surgical units where she gave medications and was interrupted multiple times.

Study: Westbrook JL et al, Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010, 170 (8): 683-690 as described in Interrupting nurses strongly linked to errors, Nursing 2010 July 2010, 19