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Interruptions Linked to Medication Errors by Nurses

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME/CE Released: 5/3/2010
  • Valid for credit through: 5/3/2011
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Target Audience and Goal Statement

This article is intended for primary care clinicians, nurses, nurse administrators, hospitalists, and other specialists who care for hospitalized patients.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the frequency of procedural failures and the association between interruptions of nursing administration of medication and rates of procedural failures.
  2. Describe the frequency of clinical errors and the association between interruptions of nursing administration of medication and clinical error rates.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Irvine, Orange, California; Director of Research and Patient Development, Family Medicine, University of California, Irvine, Medical Center, Rossmoor, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

CME Reviewer / Nurse Planner

  • Laurie E. Scudder, MS, NP

    Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland


    Disclosure: Laurie E. Scudder, MS, NP, has disclosed no relevant financial relationships.

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Interruptions Linked to Medication Errors by Nurses

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME/CE Released: 5/3/2010

Valid for credit through: 5/3/2011


May 3, 2010 — Nurses who are interrupted while administering medications may have an increased risk of making medication errors, according to the results of an observational study reported in the April 26 issue of the Archives of Internal Medicine.

"Experimental studies suggest that interruptions produce negative impacts on memory by requiring individuals to switch attention from one task to another," write Johanna I. Westbrook, PhD, from the University of Sydney in Sydney, Australia, and colleagues. "Returning to a disrupted task requires completion of the interrupting task and then regaining the context of the original task."

In 6 wards at 2 major teaching hospitals in Sydney, the investigators directly observed and recorded procedural failures and interruptions while nurses prepared and administered medications. Comparison of observational data with patients' medication charts allowed identification of clinical errors. During 505 hours from September 2006 through March 2008, a volunteer sample of 98 nurses (participation rate, 82%) gave 4271 medications to 720 adult patients.

The primary study outcomes were associations between procedural failures (10 indicators, such as aseptic technique) and clinical errors (12 indicators, such as wrong dose) and interruptions and between interruptions and potential severity of failures and errors.

Increased Rates of Procedural and Clinical Errors

For each interruption, there was a 12.1% increase in procedural failures and a 12.7% increase in clinical errors, with the association between interruptions and clinical errors independent of hospital and nurse characteristics. More than half (53.1%) of all administrations were interrupted (95% confidence interval [CI], 51.6% - 54.6%), and nearly three quarters of total drug administrations (74.4%; n = 3177) had at least 1 procedural failure (95% CI, 73.1% - 75.7%).

For administrations with no interruptions (n = 2005 administrations), the procedural failure rate was 69.6% (n = 1395; 95% CI, 67.6% - 71.6%) vs 84.6% for administrations with 3 interruptions (n = 148; 95% CI, 79.2% - 89.9%). At least 1 clinical error occurred in 25.0% of administrations overall (n = 1067; 95% CI, 23.7% - 26.3%), in 25.3% of those with no interruptions (n = 507; 95% CI, 23.4% - 27.2%), and in 38.9% of those with 3 interruptions (n = 68; 95% CI, 31.6% - 46.1%).

Nurse experience did not protect against clinical errors and was actually associated with a higher rate of procedural failure. The frequency of the interruptions was associated with increased severity of the error. The estimated risk for a major error was 2.3% when there were no interruptions vs 4.7% when there were 4 interruptions (95% CI, 2.9% - 7.4%; P < .001).

"Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors," the study authors write...."The converging evidence of the high rate of interruptions occurring during medication preparation and administration adds impetus to the need to develop and implement strategies to improve communication practices and to reduce unnecessary interruptions within ward environments. While it is clear that some interruptions are central to providing safe care, there is a need to better understand the reasons for such high interruption rates."

Limitations of this study include lack of observation of nurses during the night or on weekends and possible bias if nurses changed their behaviors when they knew they were being observed.

Commentary: Interruptions Need to Be Reduced

In an accompanying invited commentary, Julie Kliger, BA, BSN, MPA, from University of California-San Francisco, notes that to reduce medication errors, interruptions need to be reduced.

"Who, exactly, is to be held accountable for high error rates in medication administration?" Ms. Kliger writes. "The answer seems clear, as confirmed by Westbrook et al: the entire professional medical, nursing, and administrative team. The time has come for nurses, physicians, pharmacists, and all hospital staff to align behind the goal of a safer medication administration process."

The Health Contribution Fund Health, Medical Research Foundation of Australia, and the National Health and Medical Research Council supported this study. The study authors and Ms. Kliger have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:683-690, 690-692.

Additional Resource

More information on prevention of medication errors is available in articles published in the March 2010 issue of American Nurse Today and in the February 2007 issue of Family Practice Management.

Clinical Context

Interruptions of nursing administration of medications have been important contributors to medication errors, but this is largely based on self-report and retrospective analysis of voluntary reports in some studies. A total of 36 US healthcare systems found that 19% of medications administered were associated with some form of error.

This is a prospective observational study of nurses administrating medications in 2 hospital settings in Australia to examine the observer rate associated with interruptions.

Study Highlights

  • The 2 hospitals included (hospital A and hospital B) had 400 and 326 beds, respectively; these facilities were 40 miles apart.
  • The investigators undertook direct observation of 98 nurses (63 at 4 wards in hospital A and 35 in 2 wards in hospital B) in the specialty areas of geriatrics, respiratory, renal medicine, orthopaedics, and neurology and included medical and surgical patients.
  • Data were collected between 2006 and 2007 at hospital A (340 hours of direct observation) and between 2007 and 2008 at hospital B (164.75 hours).
  • Medications for patients were stored in locked bedside cabinets, and drugs of addiction (eg, opioids) and injectable medications were stored in locked medication rooms.
  • 82% of nurses recruited participated.
  • Errors were identified in the administration and preparation of medications.
  • Observers followed a "serious error" protocol in which they intervened if they observed a potentially dangerous error.
  • This occurred once during training sessions and 9 times during actual observations.
  • A structured observational tool was developed and incorporated into software on a handheld personal digital assistant.
  • Observers entered data about nursing procedures and details of medication dose, timing, and route, as well as the nurses' status (full time, part time, or on a casual basis; classification; and years of experience).
  • Interrater reliability was assessed at 16 observation sessions before data collection, and 528 drug administrations were observed by 2 researchers. The κ values, ranging from 0.94 to 0.96, indicated high reliability of agreement.
  • Direct observation was chosen because it offered more accurate data than chart or incident report review.
  • Procedural errors were classified as errors such as failure to read medication labels, failure to check patient identification, failure to record medications given, or failure to check glucose levels before administration of antidiabetic medications.
  • Clinical errors were classified as errors with drug type, dose, route of administration, timing, or administration of medications not ordered.
  • The errors were then classified by severity on a 5-point scale.
  • A total of 4271 administrations for 720 patients were observed (2592 for 514 patients at hospital A and 1679 for 206 patients at hospital B).
  • Patient mean age was 72.6 years for hospital A and 67.5 years for hospital B.
  • Only 19.8% of administrations were free of procedural and clinical errors.
  • At least 1 procedural error occurred in 74.4% of total drug administrations, and 25.0% had at least 1 clinical error.
  • The most frequent procedural error was not checking the patient's identification, which was checked in only 41.3% of administrations (n = 1732).
  • The most frequent clinical error was wrong timing (n = 688), but only 4.1% of clinical errors were of major severity.
  • Wrong intravenous administration was the second most frequent clinical error, with 35.7% rated as major.
  • Interruptions occurred in 53.1% of all administrations.
  • Procedural failure rates increased with the number of interruptions (69.6% for no interruptions and 76.7%, 78.7%, 84.6%, and 92.2% for failures with 1, 2, 3, and ≥ 4 interruptions, respectively).
  • There was a significant linear correlation with procedural failures.
  • For clinical errors, there was no significant linear correlation with the number of interruptions, but the errors also increased with interruptions.
  • The rates for clinical errors were 25.3%, 22.5%, 24.4%, 38.9%, and 30.4% for no interruptions and for 1, 2, 3, and 4 or more interruptions, respectively.
  • The associations were not affected by patient age, sex, nursing classification, age, or years of employment.
  • Overall, every interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors.
  • The risk of at least 1 clinical error occurring increased with every round of administration for each patient, from 39% with no interruptions to 61% with 5 interruptions.
  • Mean severity rating of drug administration failures and errors was 1.13, and 79.3% were insignificant (severity level 1), 2.7% were severe (severity level 4), and none were rated at level 5.
  • The authors suggested that strategies were needed to reduce interruptions to nursing administration of medications to reduce error rates.

Clinical Implications

  • Interruptions during medication administration by nurses are associated with a dose-response increase in the risk for procedural failure with each additional interruption.
  • Increased interruptions during medication administration are associated with an increased risk for clinical errors.


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