Search results for "Active Errors"

This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.

Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.

A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.

Interruptions occur frequently during the medication process, and previous studies examined whether they increase risks. This review explores the literature on the impact of interruptions during medication administration to determine factors that contribute to interruptions and how to address them.

High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.

In this prospective observational study at a psychiatric hospital, errors were identified in 3% of medication administration episodes, with omission being the most common error type. As in prior studies, interruptions and higher patient volume were associated with increased risk of mistakes.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Nursing students and new registered nurses are more likely to make mistakes during medication administration due to lack of experience and insufficient knowledge. This commentary describes the development and implementation of a simulation program to help students experience the various interruptions and distractions that occur in the hospital environment while preparing medications to understand how they can contribute to errors and learn about risks associated with multitasking.

Exploring the existing evidence on interruptions in health care, this commentary reveals that most studies focus on the rate of interruptions rather than the relationship between interruptions and errors. The author calls for research to evaluate how use of multitasking behaviors to manage interruptions and to differentiate between appropriate interruptions that prevent errors and those that contribute to preventable harm.

This study used direct observation and interviews to evaluate the effectiveness of tabards, do-not-disturb signs worn by registered nurses dispensing medications in inpatient settings, in preventing disruptions. The authors found a decrease in interruptions and medication errors, suggesting that tabards may augment safety despite controversy regarding their use.

This study used high-fidelity simulation to evaluate the impact of several interventions on preventing medication administration errors by chemotherapy nurses. Interventions with a basis in human factors engineering principles appeared to be highly effective at reducing errors related to interruptions.

Aviation strategies often guide patient safety improvement discussions. This commentary describes how a team of nurses applied the sterile cockpit concept in their unit to decrease interruptions during medication administration. The authors relate lessons learned from their experience.

This direct observation study revealed that surgical teams were distracted or interrupted an average of 9.8 times per hour, and these disruptions detracted from interoperative teamwork. Mirroring prior studies, these findings suggest that operating rooms have yet to provide an optimal environment for safe surgery despite efforts to decrease risks.

Interruptions are inevitable in the busy clinical environment and may contribute to preventable harm, particularly if they occur during medication administration. This systematic review attempted to synthesize research regarding the effectiveness of interventions that have been tested to limit interruptions during medication administration. These efforts included sterile cockpit approaches derived from the aviation industry. Although some interventions did reduce interruption rates, medication error rates were largely unaffected and the literature has significant methodological flaws. The authors caution that hospitals should not attempt to simply limit interruptions, because there is no clear evidence that doing so will prevent medication errors and some interruptions are necessary for patient care.

This systematic review identified several systems causes of medication administration errors, including interruptions, communication breakdowns, fatigue, and overall workload. A recent review found only limited evidence supporting strategies to prevent medication administration errors.

Distractions can be dangerous for patient safety, particularly during critical processes. This study describes strategies to reduce or eliminate distractions for anesthesia clinicians during the administration of nerve blocks and for nurses during final surgical counts.

In this analysis, short interruptions greatly increased sequence errors. These findings contribute to patient safety concerns about distractions during medication administration and other sequenced processes.