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Cases & Commentaries
- Web M&M
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
Journal Article > Study
Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system.
Kellogg KM, Puthumana JS, Fong A, Adams KT, Ratwani RM. J Patient Saf. 2018 Jul 7; [Epub ahead of print].
Using incident reporting data from a multihospital reporting system over a 3-year period, researchers sought to identify safety events related to interruptions. About 43% of interruption events were reported by nurses, compared to 15% by pharmacists and 7% by physicians. Interruptions most commonly involved a medication-related task.