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Journal Article > Commentary
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.
Journal Article > Study
Association of interruptions with an increased risk and severity of medication administration errors.
Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.
Interruptions in nursing activities are a known patient safety concern, particularly around medication administration. Most studies describing this relationship are based on self-reported experiences, surveys, or retrospective analysis of voluntary reports. This study directly observed nurses during medication administration and discovered that each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. Interruptions occurred in more than 50% of administrations with error severity increasing with interruption frequency. An alarming finding was that administration without interruptions still generated a procedural failure rate of nearly 70% and a clinical error rate of 25%. The latter findings are discussed further in an invited commentary [see link below] that advocates for greater efforts to improve the medication administration process, including protected times for these activities.